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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A rationale:
Radiation therapy is not typically the primary method of treatment for melanoma. Surgical excision and other therapies are often utilized.
Choice B rationale:
Metastasis in melanoma generally occurs from the outer layers of the skin to deeper levels and eventually to other parts of the body.
Choice C rationale:
Specific genetic mutations, such as mutations in the BRAF gene, are associated with an increased risk of developing melanoma.
Choice D rationale: Melanoma is a highly metastatic form of skin cancer that can spread quickly to other parts of the body. Early diagnosis and treatment are crucial to improve outcomes.
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