A client who is 38 weeks pregnant is being monitored for pre-eclampsia.
She suddenly complains of continuous abdominal pain and vaginal bleeding.
Which of the following nursing interventions should not be included in the care of this client?
Reassure the patient that she will deliver vaginally.
Insert an indwelling Foley catheter.
Initiate IV therapy with Lactated Ringer's solution.
Monitor the fetal heart tracing.
The Correct Answer is A
Choice A rationale
Reassuring the patient that she will deliver vaginally is inappropriate and could be misleading, especially if there are complications such as placental abruption or severe pre-eclampsia, which may necessitate a cesarean delivery for the safety of the mother and baby.
Choice B rationale
Inserting an indwelling Foley catheter is a standard procedure to monitor urine output and kidney function, especially in cases of pre-eclampsia, where accurate monitoring of fluid balance is crucial.
Choice C rationale
Initiating IV therapy with Lactated Ringer's solution is important to maintain maternal hydration and electrolyte balance, especially if the client is experiencing blood loss and is at risk of hypovolemia.
Choice D rationale
Monitoring the fetal heart tracing is essential to assess the baby's well-being. Continuous fetal monitoring helps detect signs of fetal distress, allowing for timely interventions to ensure the safety of both mother and baby.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Observing the perineum for signs of crowning is important, but it doesn’t address the immediate need to manage the client’s urge to push. By the time crowning is visible, delivery is imminent, and the urge to push should have been managed earlier.
Choice B rationale
Helping the client to the bathroom to void might relieve some pressure but is not the immediate priority when the client feels the urge to push. Voiding can wait until contractions are managed.
Choice C rationale
Assisting the client into a supine position is not ideal for managing the urge to push. A supine position can increase discomfort and does not facilitate optimal delivery dynamics.
Choice D rationale
Assisting the client with quick shallow breathing helps manage the urge to push and prevents premature pushing, reducing the risk of cervical injury and aiding controlled delivery.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"}}
Explanation
A. Pain: Consistent with both urinary tract infection (UTI) and preterm labor. UTI can cause dysuria and pelvic pain, while preterm labor can present with lower abdominal pain or cramping.
B. Vaginal discharge: Consistent with both urinary tract infection and preterm labor. UTI can cause unusual vaginal discharge due to infection, while increased or unusual discharge can be a sign of preterm labor.
C. Temperature: Consistent with urinary tract infection. Fever is a common symptom of UTI due to infection. Preterm labor usually does not involve a fever unless there is an infection present.
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