A nurse is developing a plan of care for a client who delivered a stillborn fetus following a placental abruption. Which of the following interventions should the nurse include?

Talk about the special features of the baby with the client.

Post a sign indicating No Visitors.

Limit the amount of time the client is allowed to have the baby in her room.

Tell the parents they should hold their baby.

Answer and Explanation

The Correct Answer is A

A) Talk about the special features of the baby with the client: This intervention acknowledges the baby as a real person and can provide comfort to the grieving parents by validating their loss and giving them a chance to create memories, which is an important aspect of the grieving process.

B) Post a sign indicating No Visitors: This may not be appropriate as it might isolate the client further. Some parents may want the support of family and friends during this difficult time, and such a restriction should be based on the parents' wishes rather than a standard protocol.

C) Limit the amount of time the client is allowed to have the baby in her room: Allowing parents to spend as much time as they need with their baby can help them with the grieving process. Placing limits might be perceived as insensitive and could hinder the emotional healing process.

D) Tell the parents they should hold their baby: While many parents find comfort in holding their stillborn baby, it should be offered as a choice rather than a directive. It is important to respect the parents' individual coping mechanisms and provide support based on their preferences.

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Correct Answer is B

Explanation

A) Place the client in a semi-Fowler's position:
While positioning can be beneficial for various conditions, it does not directly address the core issue of hypothermia. Rewarming the client effectively is the primary concern in hypothermia management.

B) Infuse warm IV fluids:
Administering warm IV fluids is a crucial intervention for moderate hypothermia as it helps increase the client's core body temperature more rapidly and effectively. This method ensures that the body's internal temperature is raised, which is vital for stabilizing the client.

C) Assess the client's skin hourly when using a heating blanket:
Monitoring the skin is important to prevent burns or skin damage from a heating blanket, but it is a supportive measure rather than a primary intervention. The key priority is to rewarm the client’s core.

D) Rewarm the client's extremities first:
Rewarming the extremities first can actually be harmful in hypothermia, as it can lead to a drop in core body temperature due to the return of cold blood from the periphery to the core (afterdrop). The focus should be on warming the core body first.

A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is A

Explanation

A) Respiratory acidosis: This condition is indicated by a low pH (7.32) and an elevated PaCO2 (48 mm Hg), while HCO3 remains normal (24 mEq/L). Respiratory acidosis occurs when there is an accumulation of carbon dioxide in the blood, usually due to hypoventilation or impaired gas exchange in the lungs.

B) Metabolic acidosis: Metabolic acidosis is characterized by a low pH and a decreased HCO3 level. In this scenario, the HCO3 level is normal, ruling out metabolic acidosis.

C) Respiratory alkalosis: Respiratory alkalosis is indicated by a high pH and a decreased PaCO2. In this case, the pH is low, and the PaCO2 is elevated, which contradicts the characteristics of respiratory alkalosis.

D) Metabolic alkalosis: Metabolic alkalosis would show a high pH and an elevated HCO3 level. Since the pH is low and the HCO3 is normal, this condition does not fit the criteria for metabolic alkalosis.

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A nurse is developing a plan of care for a client who delivered a stillborn fetus following a placental abruption. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has moderate hypothermia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory results of a client who was an unrestrained passenger in a motor-vehicle crash. The ABG results are as follows: pH 7.32, HCO3 24 mEq/L, PaCO2 48 mm Hg. The nurse should identify the client is experiencing which of the following acid-base imbalances?

Correct Answer is A

Explanation

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