A nurse is caring for a client.

Exhibits

Select the 2 actions that the nurse should take.

Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP)

Obtain serial H&H and clotting studies.

Administer misoprostol 600 mg rectally.

Place the client in a supine position.

Prepare to transfuse 2 units of packed RBCs.

Answer and Explanation

Correct Answer : A,E

A. Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP): This action is not the priority in the context of the client's current clinical status, particularly with the risk of placental abruption and severe bleeding. Fetal monitoring via scalp electrode and IUCP is typically reserved for stable clients, and invasive monitoring should be avoided in a potentially unstable situation.

B. Obtain serial H&H and clotting studies: The client is presenting with significant vaginal bleeding, low hemoglobin (8.1 g/dL at 0930, decreased to 7.5 g/dL at 1005), and low hematocrit levels (24% at 0930, dropping to 21% at 1005). Serial hemoglobin and hematocrit levels will help monitor ongoing blood loss and guide decisions regarding further interventions, such as transfusion. Clotting studies, including the prothrombin time and PTT, are necessary to assess the client's coagulation status and potential for disseminated intravascular coagulation (DIC), which can be associated with placental abruption or severe bleeding.

C. Administer misoprostol 600 mg rectally: Misoprostol is used to manage postpartum hemorrhage or to induce labor, but it is not indicated in the acute management of this client's condition. The client is 38 weeks gestation and presenting with signs of potential placental abruption, not requiring the use of misoprostol at this time.

D. Place the client in a supine position: The client should not be placed in a supine position, as this may exacerbate hypotension due to the supine hypotension syndrome, particularly if the uterus is compressing the inferior vena cava. The client would benefit more from positioning that promotes circulation, such as lying on the left side.

E. Prepare to transfuse 2 units of packed RBCs: The client is showing signs of hypovolemic shock with progressively declining blood pressure (from 95/62 mm Hg to 85/48 mm Hg), elevated heart rate (from 104/min to 128/min), and worsening hematocrit and hemoglobin. Blood transfusion is likely necessary to restore circulating volume, improve oxygen delivery, and address the ongoing blood loss.

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Correct Answer is C

Explanation

A. While medication may be helpful for sleep disturbances, offering sleep aids should not be the first response. Respite care is a more appropriate solution.

B. Although caring for someone who is terminally ill can be challenging, this response lacks empathy and does not offer practical support.

C. Respite care provides relief for caregivers by allowing them to take time off, which is appropriate for this situation.

D. While encouraging the son’s efforts is important, this response doesn't address the son's need for support or practical help with his own well-being.

A. Read medication labels at least two times prior to administration. B. Avoid preparing medications for more than two clients at one time. C. Inform clients about the action of each medication prior to administration. D. Complete an incident report if a client vomits after taking a medication.

Correct Answer is B

Explanation

A. Read medication labels at least two times prior to administration: Labels should be read three times (when retrieving, preparing, and administering).

B. Avoid preparing medications for more than two clients at one time: Reduces the risk of medication errors by minimizing task-switching and confusion.

C. Inform clients about the action of each medication prior to administration: While educating clients is essential, it is not always required before every medication.

D. Complete an incident report if a client vomits after taking a medication: An incident report is typically required only for errors or adverse events.

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A nurse is caring for a client. Exhibits Select the 2 actions that the nurse should take.

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A nurse is caring for a client.

Exhibits

Select the 2 actions that the nurse should take.