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 B
Explanation
Choice A rationale:
Waiting until school age to engage in social activities is not appropriate, as social interaction is important for a toddler's development.
Choice B rationale:
Interacting with the child according to their developmental age is important for fostering appropriate growth and development.
Choice C rationale:
Devoting more time to learning than playing may not be appropriate, as play is an essential component of early childhood development.
Choice D rationale:
Teaching several steps of a task at one time may be overwhelming for a toddler with a cognitive delay. Instructions should be simple and broken down into manageable steps.
Correct Answer is D
Explanation
Choice A rationale:
An adventitious crisis is a crisis resulting from an external event such as a natural disaster or crime.
Choice B rationale:
Psychopathologic crises involve individuals with preexisting mental health conditions experiencing acute exacerbations.
Choice C rationale:
A psychiatric emergency involves a sudden onset of severe behavioral symptoms that require immediate intervention.
Choice D rationale:
A situational crisis arises from an unexpected life event, such as injury, illness, or loss of independence, which can disrupt a person's normal routine and coping mechanisms.
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