A nurse is formulating a care plan for a patient who is 10 weeks pregnant and reports abdominal pain and moderate vaginal bleeding.
The preliminary diagnosis is an inevitable abortion.
Which nursing interventions should be included in the care plan?
Maintain the patient on bed rest.
Offer the option to view products of conception.
Administer oxygen via a nasal cannula.
Instruct the patient to increase potassium-rich foods in the diet.
The Correct Answer is A
Choice A rationale
Maintain the patient on bed rest. This is a common nursing intervention for a patient who is experiencing an inevitable abortion. Bed rest can help reduce the risk of further complications, such as heavy bleeding. It can also provide the patient with a chance to rest and recover physically and emotionally.
Choice B rationale
Offer the option to view products of conception. This intervention may not be appropriate for all patients. While some patients may find it helpful to view the products of conception, others may find it distressing. It’s important to discuss this option with the patient and respect her wishes.
Choice C rationale
Administer oxygen via a nasal cannula. This intervention may not be necessary for all patients experiencing an inevitable abortion. While oxygen therapy can be used to treat hypoxia in patients with heavy bleeding, it’s not typically required unless the patient shows signs of hypoxia.
Choice D rationale
Instruct the patient to increase potassium-rich foods in the diet. This intervention is not typically part of the care plan for a patient experiencing an inevitable abortion. While a balanced diet is important for overall health, there’s no specific need to increase potassium-rich foods in the diet in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Based on your last menstrual period (LMP) of May 4, 2022, your estimated date of delivery (EDD) would be around February 11, 2023."
Rationale:
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Calculating the Estimated Date of Delivery (EDD): The EDD can be calculated using Naegele's Rule, which is a standard method used to estimate the due date. The rule involves subtracting three months from the first day of the last menstrual period (LMP), adding seven days, and adjusting the year if necessary.
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Application of Naegele’s Rule:
- Start with the first day of the LMP: May 4, 2022.
- Subtract three months: February 4, 2022.
- Add seven days: February 11, 2022.
- Since the year needs to be adjusted, the EDD is February 11, 2023.
Key Points:
- Naegele’s Rule is commonly used but assumes a 28-day menstrual cycle and ovulation on the 14th day. Variations in cycle length can affect the accuracy.
Correct Answer is C
Explanation
Choice A rationale
While it might seem helpful to offer to tell the parents for the client, it’s important to respect the client’s autonomy and confidentiality. The nurse should support the client in making their own decisions about disclosure.
Choice B rationale
It’s not necessarily true that the parents will have to be told why the client is being admitted. Confidentiality is a key aspect of healthcare, especially when it comes to sensitive issues like sexually transmitted infections.
Choice C rationale
This response is empathetic and non-judgmental. It acknowledges the client’s feelings and opens up a conversation without forcing any action. This allows the client to feel heard and supported, which is crucial in a healthcare setting.
Choice D rationale
While this response might be well-intentioned, it assumes that the parents will understand and doesn’t acknowledge the client’s fear or concern. It’s important for the nurse to validate the client’s feelings and provide support.
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