In caring for the woman with disseminated intravascular coagulation (DIC), which order should the nurse anticipate?
Administration of steroids
Administration of blood
Restriction of intravascular fluids
Preparation of the client for invasive hemodynamic monitoring
The Correct Answer is B
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse's first action should be to massage the woman's fundus. A completely saturated perineal pad within 15 minutes after giving birth indicates excessive bleeding, which is also known as postpartum hemorrhage (PPH). Massaging the uterus (fundus) can help it to contract, reduce bleeding, and prevent further blood loss. Once the fundus has been massaged, the nurse should assess the woman's vital signs and continue to monitor her for signs of continued bleeding. If bleeding persists despite massage, the nurse should begin an intravenous (IV) infusion of Ringer's lactate solution and call the woman's primary healthcare provider.
Correct Answer is C
Explanation
A CS4 who has had three prior lower transverse cesarean sections is at the highest risk for uterine rupture. The risk of uterine rupture increases with each subsequent cesarean section, and a history of three or more prior lower transverse cesarean sections is considered a significant risk factor for uterine rupture.
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