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 pointing out how lucky she is to have a healthy baby may invalidate her feelings and make her feel guilty or ashamed. The nurse should acknowledge and respect the client's emotions and avoid making judgments or comparisons.
Choice B: This is incorrect because assessing her for pain is not the first action that the nurse should take. Although pain may be a factor that contributes to the client's emotional state, it is not the primary cause of her crying. The nurse should first establish rapport and trust with the client and then assess her physical and psychological needs.
Choice C: This is incorrect because explaining that she is experiencing postpartum blues may be premature and inaccurate. Postpartum blues are mild and transient mood changes that occur in up to 80% of women within the first few days after childbirth. They are characterized by tearfulness, irritability, anxiety, and mood swings. However, the nurse should not assume that the client has postpartum blues without performing a thorough assessment and ruling out other possible causes of her crying, such as postpartum depression, anxiety, or trauma.
Choice D: This is the correct answer because allowing her time to express her feelings is the most appropriate and empathetic action that the nurse should take first. The nurse should listen actively and attentively to the client and provide emotional support and reassurance. The nurse should also use open-ended questions and reflective statements to facilitate communication and explore the client's concerns and coping strategies.
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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