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:
Understanding the relationship between food intake and the menstrual cycle is a relevant topic for individuals with anorexia nervosa.
Choice B rationale:
Rapid weight gain of 2 pounds per week can be concerning and may indicate an unhealthy pattern or behaviors related to the eating disorder.
Choice C rationale:
Recognizing that the body will never be perfect is a positive and realistic perspective that can contribute to a healthier mindset in individuals with anorexia nervosa.
Choice D rationale:
Taking a laxative for constipation is not uncommon among individuals with eating disorders, but the statement doesn't necessarily raise immediate concern compared to the rapid weight gain mentioned in choice B.
Correct Answer is A
Explanation
Choice A rationale:
Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.
Choice B rationale:
A fetal heart rate of 120/min is within a normal range and is not concerning.
Choice C rationale:
Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.
Choice D rationale:
Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.
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