A nurse is caring for a client who is at 32 weeks of gestation.
Administer betamethasone IM
Prepare client for an immediate cesarean birth
Perform vaginal exams every shift
Provide continuous external fetal heart monitoring
Provide the client with instructions about limiting activity
Monitor intake and output
Prepare and transfuse A-positive blood products
Correct Answer : A,D,E,F
Rationale:
A. Administer betamethasone IM to enhance fetal lung maturity in case of preterm delivery (<34 weeks).
B. Immediate cesarean birth is not indicated unless there is heavy bleeding or fetal distress. The client is stable with normal FHR and moderate variability.
C. Vaginal examinations are contraindicated in placenta previa because they can cause placental separation and severe hemorrhage.
D. Continuous external fetal heart monitoring helps assess fetal well-being and detect distress due to bleeding or hypoxia.
E. Activity limitation reduces uterine activity and the risk of further bleeding. The client should avoid sexual activity and strenuous exercise.
F. Monitoring intake and output helps assess renal perfusion, especially if bleeding increases or the client develops hypotension.
G. Transfusing A-positive blood is inappropriate because the client’s type is A-negative; incompatible transfusion would cause hemolytic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Interleukin-6 is a marker of inflammation, not a direct indicator for antidepressant therapy.
B. Depression is linked to decreased serotonin, norepinephrine, and dopamine levels. Antidepressants (SSRIs, SNRIs, TCAs, MAOIs) act by increasing serotonin availability, improving mood and energy levels.
C. C-reactive protein relates to inflammation and infection, not mood disorders.
D. Urine cortisol levels may reflect stress but are not diagnostic for depression.
Correct Answer is C
Explanation
A. Family planning: This is primary prevention, aimed at preventing unwanted pregnancies and promoting reproductive health.
B. Diabetes screening: Screening is secondary prevention, identifying disease early to prevent progression.
C. Physical therapy: Tertiary prevention focuses on rehabilitation and restoration of function after disease or injury has occurred. Physical therapy helps clients regain mobility and prevent complications in chronic or post-acute conditions.
D. Nutrition counseling: Nutrition counseling can be primary or secondary prevention depending on the context, but it is not tertiary unless focused on managing existing disease complications.
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