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 B
Explanation
Choice A rationale:
Magical thinking is a positive symptom of schizophrenia, involving unrealistic beliefs or perceptions.
Choice B rationale:
A flat affect is a negative symptom of schizophrenia characterized by reduced emotional expression. Negative symptoms involve a decrease or loss of normal functioning, and a flat affect is one of the most common negative symptoms seen in schizophrenia.
Choice C rationale:
Ideas of reference are also a positive symptom, involving the belief that neutral or unrelated events have special significance related to oneself.
Choice D rationale:
Clang association is another positive symptom, involving the association of words based on similar sounds rather than meaningful connections
Correct Answer is B
Explanation
A. Taking estrogen supplements does not significantly increase infection risk in clients receiving chemotherapy.
B. A 70-year-old client with chronic obstructive pulmonary disease (COPD) is at greatest risk for infection because advanced age and chronic lung disease both impair immune function and increase susceptibility to respiratory infections, especially during chemotherapy.
C. A left arm fracture may increase local infection risk, but it does not pose as high a systemic infection risk as COPD in an older adult.
D. Having a thin build does not inherently increase infection risk in the context of chemotherapy.
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