A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
Administer oxygen via nasal cannula.
Offer option to view products of conception.
Instruct the client to increase potassium-rich foods in the diet.
Maintain the client in a Trendelenburg position.
The Correct Answer is B
Choice A reason: Administering oxygen via nasal cannula is not a necessary intervention for the client, unless she has signs of hypoxia, such as dyspnea, tachypnea, or cyanosis. Oxygen administration is not routinely indicated for clients with inevitable abortion.
Choice B reason: Offering option to view products of conception is an appropriate intervention for the client, because it can help her cope with the loss of pregnancy and facilitate the grieving process. The nurse should respect the client's decision and provide emotional support.
Choice C reason: Instructing the client to increase potassium-rich foods in the diet is not a relevant intervention for the client, unless she has signs of hypokalemia, such as muscle weakness, cramps, or arrhythmias. Potassium intake is not related to the cause or prevention of inevitable abortion.
Choice D reason: Maintaining the client in a Trendelenburg position is not a recommended intervention for the client, because it can increase the risk of aspiration, respiratory compromise, and venous congestion. Trendelenburg position is not effective in preventing or treating inevitable abortion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Calcium carbonate is not the compound that the nurse should have readily available, as it is an antacid that neutralizes stomach acid and relieves heartburn. Calcium carbonate is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice B reason: Potassium chloride is not the compound that the nurse should have readily available, as it is an electrolyte supplement that replenishes potassium levels and prevents hypokalemia. Potassium chloride is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice C reason: Ferrous sulfate is not the compound that the nurse should have readily available, as it is an iron supplement that prevents or treats iron deficiency anemia. Ferrous sulfate is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice D reason: Calcium gluconate is the compound that the nurse should have readily available, as it is an antidote that reverses the effects of magnesium sulfate and restores calcium levels and neuromuscular function. Calcium gluconate is used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Correct Answer is A
Explanation
Choice A reason: Asymmetric thigh folds is a common finding in newborns who have DDH, because the affected hip is dislocated or subluxated, causing the thigh to appear shorter and the skin folds to be uneven. The nurse should compare the number and depth of the skin folds on both sides of the groin and buttocks.
Choice B reason: Absent plantar reflexes is not a typical finding in newborns who have DDH, because it is not related to the hip joint. The plantar reflex is a normal reflex that causes the toes to curl when the sole of the foot is stroked. The nurse should assess the plantar reflex in all newborns, regardless of their hip status.
Choice C reason: Lengthened thigh on the affected side is not a usual finding in newborns who have DDH, because the opposite is true. The affected thigh is usually shorter than the unaffected thigh, due to the displacement of the femoral head from the acetabulum. The nurse should measure the length of both thighs from the anterior superior iliac spine to the medial malleolus.
Choice D reason: Inwardly turned foot on the affected side is not a specific finding in newborns who have DDH, because it can be caused by other conditions, such as metatarsus adductus or clubfoot. The inward turning of the foot is not a direct result of the hip disorder, but rather a secondary effect of the abnormal positioning of the leg. The nurse should examine the alignment and mobility of the foot and ankle.
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