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 C
Explanation
Choice a) Have the parent fold the infant's arms across the chest is incorrect because this is not a helpful way to calm a preterm infant. Folding the arms across the chest can restrict the infant's breathing and movement, and may increase their stress and discomfort. Preterm infants need gentle and supportive touch, not restraint or pressure.
Choice b) Encourage the parent to place the infant back in the warmer is incorrect because this is not a necessary or beneficial action for a preterm infant who is showing signs of overstimulation. Placing the infant back in the warmer can interrupt the bonding and attachment process between the parent and the infant, and may make the infant feel more isolated and insecure. Preterm infants need close and frequent contact with their parents, not separation or detachment.
Choice c) Encourage the parent to do kangaroo care is correct because this is an effective and evidence-based method of soothing and stabilizing a preterm infant who is experiencing overstimulation. Kangaroo care is a technique where the parent holds the infant skin-to-skin on their chest, providing warmth, comfort, and security. Kangaroo care can reduce the infant's stress hormones, lower their heart rate and blood pressure, improve their oxygenation and breathing, enhance their growth and development, and strengthen their bond with their parent.
Choice d) Cover the infant with a warm bed blanket is incorrect because this is not a sufficient or optimal way to comfort a preterm infant who is displaying signs of overstimulation. Covering the infant with a warm bed blanket can provide some warmth and protection, but it does not offer the same benefits as kangaroo care. A warm bed blanket cannot mimic the parent's heartbeat, voice, smell, and movement, which are essential for the infant's emotional and physiological well-being. Preterm infants need human touch and interaction, not just physical warmth.
Correct Answer is D
Explanation
Choice A) Weight gain of 0.5 kg during the past 2 weeks: This is a normal weight gain for a pregnant woman and does not indicate preeclampsia.
Choice B) Pitting pedal edema at the end of the day: This is a common symptom of pregnancy and does not necessarily indicate preeclampsia. It can be relieved by elevating the legs and wearing compression stockings.
Choice C) Blood pressure increase to 138/86 mm Hg: This is a mild elevation of blood pressure and does not meet the criteria for preeclampsia, which is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least four hours apart.
Choice D) Dipstick value of 3+ for protein in her urine: This is a sign of significant proteinuria, which is one of the main features of preeclampsia. Proteinuria is defined as a urinary protein excretion of 300 mg or more in 24 hours or a dipstick reading of 1+ or higher. A dipstick value of 3+ indicates severe proteinuria and requires immediate attention and treatment. This woman has the highest risk of developing complications from preeclampsia, such as eclampsia, HELLP syndrome, placental abruption, or fetal growth restriction . Therefore, she should be seen by the nurse first.
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