A patient arrives at OB triage with a complaint of vaginal bleeding. The nurse would prioritize all of the following questions during the assessment except:
How many weeks are you?
Are you experiencing any pain?"
When was your last ultrasound?
"Do you plan to have a vaginal or cesarean delivery?"
The Correct Answer is D
The question that the nurse would prioritize the least during the assessment is "Do you plan to have a vaginal or cesarean delivery?" This is because the priority at this point is to determine the urgency of the situation and assess the patient's current condition. The patient's delivery plan can be addressed later after the initial assessment is completed and the patient's stability has been established.
The other questions are all important in determining the cause and severity of the bleeding and the appropriate course of action. The question about the number of weeks is important to determine the gestational age and potential causes of bleeding, as some causes are more common in certain stages of pregnancy. The question about pain can help to determine the possible causes of bleeding and the patient's comfort level. The question about the last ultrasound is important to determine the location of the placenta and whether there are any abnormalities or potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
In DIC, there is widespread clotting that can lead to depletion of clotting factors and platelets, resulting in bleeding. The priority in the care of DIC is to correct the underlying cause and to replace lost blood products to prevent hypovolemia and hemorrhage. Therefore, the nurse should anticipate an order for the administration of blood products such as packed red blood cells, fresh frozen plasma, and platelets. Administration of steroids may also be ordered to reduce inflammation and stabilize cell membranes. Restriction of intravascular fluids may be necessary to prevent further bleeding, but it is not the first priority. Invasive hemodynamic monitoring may be used to assess the client's fluid and electrolyte status, but it is not typically the first intervention.
Correct Answer is C
Explanation
This tool helps in assessing the severity of withdrawal symptoms in infants who were exposed to opioids during pregnancy. Based on the Finnegan score, the nurse can implement appropriate interventions to manage the symptoms and prevent complications. While offering the infant a pacifier with a drop of mom's breast milk or tightly swaddling the infant may be helpful for soothing the infant, these interventions may not directly address the underlying hyperreflexia associated with opioid withdrawal. Placing the infant under a radiant warmer is not indicated for managing hyperreflexia.
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