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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Placing the newborn under a radiant warmer is not directly related to addressing breastfeeding-related jaundice.

Choice B rationale:

Supplementing breastfeeding with formula is not the first-line approach and may interfere with establishing successful breastfeeding.

Choice C rationale:

Breastfeeding-related jaundice can occur if the newborn is not effectively breastfeeding and not getting enough milk. Assessing the effectiveness of breastfeeding is important to address the underlying cause of jaundice.

Choice D rationale:

Administering Rho(D) immune globulin is unrelated to addressing jaundice in a breastfed newborn.

A. Decreased albumin B. Decreased erythrocyte sedimentation rate C. Increased hematocrit D. Increased protein

Correct Answer is A

Explanation

Choice A rationale:

Inflammatory bowel disease, including Crohn's disease, can lead to decreased albumin levels due to malabsorption and inflammation.

Choice B rationale:

Increased erythrocyte sedimentation rate (ESR) is more likely in inflammatory conditions.

Choice C rationale:

Decreased hematocrit is more common due to potential blood loss.

Choice D rationale:

Decreased protein levels are expected due to inflammation and malabsorption.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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