A nurse is providing care for an adolescent who was brought to the emergency department (ED) by their guardians due to pain in the left arm that started the previous evening.

The adolescent has a history of sickle cell disease diagnosed at age 4. They have a prescription for oral morphine sulfate and took one dose the previous evening at 1800 and another this morning at 0900.

The adolescent reports no relief from pain, rating it as 9 on a scale of 0 to 10. For each potential provider’s prescription, specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Intravenous fluids (IVF) at maintenance rate

Meperidine IV for pain

Ice packs to the affected area for 15 min on/15 min off

Oxygen 2 L/min via nasal cannula

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Choice A rationale
Intravenous fluids (IVF) at maintenance rate is anticipated for the client. Dehydration can increase the viscosity of the blood and promote sickling in clients with sickle cell disease. Therefore, maintaining hydration is crucial in managing sickle cell crises.
Choice B rationale
Meperidine IV for pain is contraindicated for the client. Meperidine has been associated with a higher risk of seizures, especially in clients with kidney dysfunction, which can occur in sickle cell disease due to sickling in the renal vasculature.
Choice C rationale
Ice packs to the affected area for 15 min on/15 min off is nonessential for the client. While cold therapy can help reduce inflammation and numb pain, it can also lead to vasoconstriction, which can potentially exacerbate sickling. Therefore, it’s generally recommended to use warm compresses rather than ice packs in clients with sickle cell disease.
Choice D rationale
Oxygen 2 L/min via nasal cannula is anticipated for the client. Hypoxia can trigger sickling in clients with sickle cell disease, so oxygen therapy is often used to increase oxygen saturation and reduce the risk of sickling.

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Correct Answer is C

Explanation

Choice A rationale
Limiting noise and interruption in the delivery room can help create a calm environment, which can be beneficial for both the mother and the newborn. However, this is not the priority action for promoting maternal-infant bonding.
Choice B rationale
Encouraging parents to touch and explore the neonate’s features can help foster a connection between the parents and the newborn. This tactile stimulation can also be comforting for the newborn. However, this is not the most immediate action to promote maternal-infant bonding.
Choice C rationale
Placing the neonate skin-to-skin on the client’s chest is the priority action. Skin-to-skin contact immediately after birth helps regulate the newborn’s temperature, heart rate, and breathing. It also promotes breastfeeding and bonding.
Choice D rationale
Placing the neonate at the client’s breast can promote breastfeeding, which can enhance maternal-infant bonding. However, this is not the first action to take. The priority is to establish skin-to-skin contact.

A. Monitor vaginal bleeding. B. Administer glucocorticoids. C. Insert an IV catheter. D. Apply an external fetal monitor.

Correct Answer is A

Explanation

Choice A rationale
Monitoring vaginal bleeding is the priority nursing action for a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Placenta previa can cause painless, bright red vaginal bleeding during the third trimester. This bleeding can lead to serious complications for both the mother and the fetus, making it crucial to monitor for this symptom.
Choice B rationale
Administering glucocorticoids is not the priority nursing action in this situation. While glucocorticoids can be used to accelerate fetal lung maturity in cases of preterm labor, they are not the primary treatment for placenta previa.
Choice C rationale
Inserting an IV catheter may be necessary for administering medications or fluids, but it is not the priority action. The nurse’s primary concern should be monitoring for signs of bleeding.
Choice D rationale
Applying an external fetal monitor can help assess the well-being of the fetus, but it is not the priority action. The nurse’s main focus should be on monitoring for vaginal bleeding.

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Naxlex Comprehensive Predictor Exams

A nurse in the delivery room is planning to promote maternal-infant bonding for a client who just delivered. What is the priority action by the nurse?

Correct Answer is C

Explanation

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. What is the priority nursing action?

Correct Answer is A

Explanation

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