A nurse is planning care for a client who is experiencing moderate vaginal bleeding due to a placental abruption. Which of the following interventions should the nurse include in the plan?
Check cervical dilation every 2 hr.
Initiate an IV with an 18-gauge catheter.
Monitor FHR hourly.
Obtain vital signs every 4 hr.
The Correct Answer is B
Choice A rationale:
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
Choice B rationale:
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
Choice C rationale:
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
Choice D rationale:
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Children with autism spectrum disorder often have difficulty with transitions and new situations. Introducing new situations slowly can help reduce anxiety and support a smoother adjustment.
Choice B rationale:
Administering valproic acid is not a nursing intervention for autism spectrum disorder.
Choice C rationale:
Allowing the toddler to choose the daily routine might not be effective as they may struggle with decision-making and may prefer structured routines.
Choice D rationale:
Increasing stimulation in the toddler's environment might overwhelm a child with autism, who often prefers a calm and predictable environment.
Correct Answer is A
Explanation
Choice A rationale:
Keeping the television on at a low volume in the background can provide sensory stimulation and a familiar environment for the client with Alzheimer's disease. It can also help decrease feelings of isolation and confusion.
Choice B rationale:
Abstract paintings may be confusing or agitating for a person with Alzheimer's disease. Familiar and recognizable decorations are more suitable.
Choice C rationale:
Reorienting the client daily to the day and time can be helpful, but it is not the priority teaching in this context.
Choice D rationale:
Using dim lighting is not recommended as it can contribute to confusion and disorientation in a person with Alzheimer's disease. Adequate lighting is important for safety and orientation.
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