A nurse in an antepartum unit is caring for a client.
Monitor blood pressure every hour.
Initiate an IV infusion of lactated Ringer's.
Place the client in a left lateral position.
Maintain continuous monitoring of the FHR.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
- Monitor blood pressure every hour: Frequent blood pressure monitoring is necessary due to the client’s history of chronic hypertension and gestational diabetes, both of which increase the risk for preeclampsia.
- Initiate an IV infusion of lactated Ringer's: IV fluids help maintain hydration, support uteroplacental perfusion, and provide a route for medications if needed. This is a routine step in labor management.
- Place the client in a left lateral position: This position enhances uteroplacental circulation by reducing pressure on the inferior vena cava, especially important when fetal heart rate shows minimal variability.
- Maintain continuous monitoring of the FHR: Minimal variability and elevated baseline (168/min) warrant continuous fetal monitoring to assess for potential fetal distress or effects of meconium-stained fluid.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Explain what you were doing to get hit." This statement implies blame or justification for the abuse and can cause the child to feel guilt or shame, which is inappropriate and non-therapeutic.
B. "Why do you think that you are being abused?" This question may sound accusatory or suggest that the child is responsible for the abuse. It can discourage open communication and retraumatize the child.
C. "I am sure everything will work out just fine." This is a false reassurance. It dismisses the child’s emotions and does not validate their experience, which can hinder trust-building.
D. "Can you tell me how you are feeling?" This open-ended, nonjudgmental question encourages the child to express emotions and builds therapeutic rapport. It provides emotional support in a safe, respectful manner.
Correct Answer is D
Explanation
A. When the client has a cognitive disorder:A cognitive disorder does not automatically remove a client’s right to confidentiality. Information should still be protected unless the client has a legal guardian or specific exceptions apply.
B. When the client's hospitalization is involuntary:Even in involuntary admissions, the client retains rights to confidentiality. Disclosure requires consent unless there is a risk of harm to self or others.
C. When a member of the client's immediate family requests information:Confidentiality must be maintained unless the client provides explicit permission for the information to be shared with family.
D. When the client has communicated an intention to harm someone:This is an exception to confidentiality. The nurse has a legal and ethical duty to report threats of harm to protect potential victims (duty to warn).
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