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: This is incorrect because weight less than the 10th percentile (SGA) means that the infant is smaller than expected for the gestational age, but not necessarily low birth weight. SGA infants may have intrauterine growth restriction due to maternal, placental, or fetal factors, but they may also be constitutionally small. SGA infants are at risk for hypoglycemia, hypothermia, polycythemia, and perinatal asphyxia.
Choice B: This is incorrect because weight greater than the 90th percentile means that the infant is larger than expected for the gestational age, but not necessarily high birth weight. Infants with weight greater than the 90th percentile are called large for gestational age (LGA) or macrosomic. LGA infants may have maternal diabetes, genetic factors, or post-term pregnancy as causes, but they may also be constitutionally large. LGA infants are at risk for birth trauma, shoulder dystocia, hypoglycemia, and respiratory distress.
Choice C: This is incorrect because weight between the 10th and 90th percentile means that the infant is appropriate for the gestational age (AGA), but not necessarily normal birth weight. AGA infants have a weight that matches their gestational age and are considered healthy and well-nourished. However, some AGA infants may have low or high birth weight depending on their gestational age at birth.
Choice D: This is the correct answer because low birth weight (LBW) is defined as a weight of 2500g or less at birth, regardless of the gestational age. LBW infants may be preterm (born before 37 weeks of gestation), term (born between 37 and 42 weeks of gestation), or post-term (born after 42 weeks of gestation). LBW infants are at risk for infection, bleeding, jaundice, and neurodevelopmental problems.
Correct Answer is C
Explanation
Choice A) dilates the bronchioles, decreasing airway resistance: This is not the correct function of surfactant.
Surfactant is a substance that reduces the surface tension of the fluid that lines the alveoli, which are the tiny air sacs in the lungs where gas exchange occurs. Surfactant does not affect the diameter of the bronchioles, which are the small airways that branch from the bronchi. Bronchodilation and bronchoconstriction are regulated by the autonomic nervous system and various mediators, such as histamine, epinephrine, and acetylcholine.
Choice B) provides transportation for oxygen to enter the blood supply: This is not the correct function of surfactant. Surfactant does not transport oxygen or any other gas. Oxygen diffuses from the alveoli into the capillaries, where it binds to hemoglobin in the red blood cells. The red blood cells then transport oxygen to the tissues via the blood circulation. Surfactant does not play a role in this process.
Choice C) keeps the alveoli open during expiration: This is the correct function of surfactant. Surfactant prevents the alveoli from collapsing during expiration by lowering the surface tension of the fluid that lines them. This allows for easier breathing and better gas exchange. Without enough surfactant, the alveoli tend to collapse and stick together, causing atelectasis, which is a condition where some or all of a lung collapses. Atelectasis can lead to hypoxia, respiratory distress, and infection.
Choice D) causes increased permeability of the alveoli: This is not the correct function of surfactant. Surfactant does not increase or decrease the permeability of the alveoli, which is the ability of substances to pass through them.
Permeability of the alveoli depends on several factors, such as pressure gradients, solubility, molecular size, and membrane thickness. Increased permeability of the alveoli can occur in conditions such as acute respiratory distress syndrome (ARDS), where fluid leaks into the alveolar space and impairs gas exchange. Surfactant does not cause this condition, but it can be affected by it.
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