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 C
Explanation
Choice A rationale:
Restricting fluid intake is not the primary concern when taking lithium. It's more important to maintain a consistent level of sodium intake.
Choice B rationale:
Doubling the dose of lithium without medical supervision can lead to lithium toxicity, which can be life-threatening.
Choice C rationale:
Sodium levels can impact the effectiveness and safety of lithium. Consuming a moderate- sodium diet helps prevent sodium depletion or overload, which can affect lithium levels.
Choice D rationale:
Slurred speech is not indicative of low lithium levels. It's important to monitor for signs of lithium toxicity, which include tremors, confusion, and GI symptoms.
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.
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.