The student nurse is assessing a woman with abruptio placentae. The student reports to the registered nurse, "I can't really palpate her abdomen, it's as hard as a board." What action by the nurse is the priority?
Assess the woman's fundal height and vital signs.
Administer a dose of opioid pain medication.
Tell the student to document the findings.
Have the student teach the woman relaxation techniques.
The Correct Answer is A
Choice A: This is the correct answer because a hard and tender abdomen is a sign of concealed hemorrhage, which can lead to hypovolemic shock and fetal distress. The nurse needs to monitor the woman's blood loss, blood pressure, pulse, and fetal heart rate to detect any complications and intervene accordingly.
Choice B: This is incorrect because opioid pain medication can mask the signs of shock and fetal distress, and may also cause respiratory depression in both the mother and the fetus. Pain relief should be given after assessing the woman's condition and consulting with the physician.
Choice C: This is incorrect because documenting the findings is not a priority action. The nurse needs to act quickly to prevent further blood loss and fetal compromise, and report the findings to the physician.
Choice D: This is incorrect because relaxation techniques may not be effective in reducing the pain and anxiety caused by abruptio placentae. The nurse should provide emotional support and reassurance to the woman, but also focus on assessing and managing her physical condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a) We are protecting the infant from our bacteria is incorrect because this is not the main reason why gloves are needed when handling a newborn. While it is true that newborns have immature immune systems and are susceptible to infections, gloves are not only used to protect the infant from our bacteria but also to protect ourselves from the infant's body fluids and secretions, which may contain pathogens or blood-borne diseases.
Therefore, this response is incomplete and misleading.
Choice b) Amniotic fluid and maternal blood pose risks to us is incorrect because this is also not the primary reason why gloves are needed when handling a newborn. While it is true that amniotic fluid and maternal blood may contain harmful microorganisms or viruses that can infect us, gloves are not only used to protect ourselves from these substances but also to protect the infant from our skin flora and potential contaminants, which may cause skin irritation or infection. Therefore, this response is also incomplete and misleading.
Choice c) It is hospital policy is incorrect because this is not a sufficient or satisfactory reason why gloves are needed when handling a newborn. While it is true that wearing gloves may be a hospital policy or protocol, this response does not explain the rationale or evidence behind this policy and may imply that the nurse does not understand or agree with it. Therefore, this response is vague and unprofessional.
Choice d) It is part of standard precautions is correct because this is the best and most accurate reason why gloves are needed when handling a newborn. Standard precautions are a set of guidelines and practices that aim to prevent the transmission of infections in healthcare settings. They include wearing gloves, gowns, masks, and eye protection when there is a risk of exposure to blood or body fluids, as well as washing hands before and after patient contact, cleaning and disinfecting equipment and surfaces, and disposing of waste properly. Standard precautions apply to all patients, regardless of their diagnosis or infection status, and are based on the principle that all blood and body fluids are potentially infectious. Therefore, this response is clear and appropriate.
Correct Answer is B
Explanation
Choice a) Document the event in the nurses' notes is incorrect because this is not a priority action for a neonate who is showing signs of hypoglycemia. Hypoglycemia is a condition where the blood glucose level is lower than normal, which can cause neurological and metabolic problems in newborns. Neonates of diabetic mothers are at higher risk of developing hypoglycemia due to increased insulin production and decreased glycogen stores.
Documenting the event in the nurses' notes is an important step, but it should be done after assessing and treating the neonate's condition.
Choice b) Test for blood glucose level is correct because this is the most important action for a neonate who is exhibiting symptoms of hypoglycemia. The nurse should use a heel stick or a cord blood sample to measure the blood glucose level of the neonate as soon as possible, as hypoglycemia can lead to serious complications such as seizures, coma, brain damage, or death if left untreated. The normal blood glucose range for a full-term neonate is 40 to 60 mg/dL in the first hour of life, and 50 to 90 mg/dL thereafter. A blood glucose level below 40 mg/dL indicates hypoglycemia and requires immediate intervention.
Choice c) Notify the clinician stat is incorrect because this is not the most urgent action for a neonate who is suffering from hypoglycemia. The nurse should notify the clinician after confirming the diagnosis of hypoglycemia and initiating treatment, such as feeding or administering intravenous glucose. The clinician may order further tests or treatments depending on the severity and cause of the hypoglycemia, but the nurse should not delay the initial management of the neonate's condition.
Choice d) Start an intravenous line with D5W is incorrect because this is not the first-line treatment for a neonate who has hypoglycemia. D5W stands for dextrose 5% in water, which is a solution that contains glucose and water. It can be used to treat hypoglycemia by providing a source of energy and fluid to the neonate. However, before starting an intravenous line with D5W, the nurse should first attempt to feed the neonate with breast milk or formula, as this can also raise the blood glucose level and provide other nutrients and antibodies. If feeding is unsuccessful or contraindicated, then the nurse should start an intravenous line with D5W as ordered by the clinician.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today