A nurse is caring for a client who is at risk for developing intraventricular hemorrhage (IVH).
Which action should the nurse take to reduce the client's risk?
Encouraging early ambulation
Administering medications to induce hypercoagulability
Monitoring the client's blood glucose levels
Maintaining a neutral head position
The Correct Answer is D
Maintaining a neutral head position. This action can help reduce the client’s risk of intraventricular hemorrhage (IVH) by preventing fluctuations in intracranial pressure that could rupture blood vessels in the brain.
Choice A is wrong because encouraging early ambulation can increase the risk of IVH by causing changes in blood pressure and cerebral perfusion.
Choice B is wrong because administering medications to induce hypercoagulability can increase the risk of IVH by promoting thrombosis and impairing blood flow to the brain.
Choice C is wrong because monitoring the client’s blood glucose levels is not directly related to the prevention of IVH, although it may be important for other reasons such as avoiding hypoglycemia or hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Mild lower abdominal cramping is a sign of preterm laborand should be prioritized as a potential complication.Preterm labor occurs when regular contractions begin to open your cervix before 37 weeks of pregnancy.
A full-term pregnancy should last about 40 weeks.
Choice B is wrong because a change in vaginal discharge color is not a specific sign of preterm labor.
It could be due to other factors such as infection or normal hormonal changes.
Choice C is wrong because a brief episode of low back pain is not a sign of preterm labor.
It could be due to posture, muscle strain or other causes.
Choice D is wrong because occasional fetal hiccups are not a sign of preterm labor.
They are normal movements of the fetus and do not indicate any distress or danger.
Correct Answer is C
Explanation
Performing a speculum examination of the vagina and cervix.
This is because a speculum examination can help determine the presence of cervical dilation, effacement, or infection, which are signs of pre-term labor.
A speculum examination can also detect the presence of fetal fibronectin, which is a protein that indicates an increased risk of pre-term delivery.
Choice A is wrong because obtaining a detailed history of previous pregnancies is not a priority assessment for pre-term labor.
While it can provide some information about the client’s risk factors, it does not indicate the current status of the pregnancy or the cervix.
Choice B is wrong because checking the fetal heart rate and activity is not a priority assessment for pre-term labor.
While it can provide some information about the fetal well-being, it does not indicate the presence or absence of contractions or cervical changes.
Choice D is wrong because performing laboratory tests, such as urine culture, is not a priority assessment for pre-term labor.
While it can help identify possible infections that may contribute to pre-term labor, it does not provide immediate results or indicate the current status of the cervix.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.