A nurse is assisting with the care of a client who presents to the labor and delivery unit.
The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.
Perform intermittent external electronic fetal monitoring.
Monitor vital signs at least every 15 min.
Place the client in a supine position.
Obtain type and crossmatch.
Measure blood loss by weighing pads.
Insert a large-bore IV catheter.
Correct Answer : B,D,E,F
Choice A rationale:
Performing intermittent external electronic fetal monitoring is not the best choice in this situation. The client’s condition, which includes severe abdominal pain, vaginal bleeding, rigid and tender abdomen, and late decelerations in the fetal heart rate, suggests a possible placental abruption. In such a case, continuous fetal monitoring is required to closely monitor the fetal heart rate and contractions.
Choice B rationale:
Monitoring vital signs at least every 15 min is necessary. The client’s blood pressure has dropped from 110/68 mm Hg to 95/59 mm Hg within 15 minutes. This could indicate hypovolemia due to blood loss. Regular monitoring can help detect changes early and initiate appropriate interventions.
Choice C rationale:
Placing the client in a supine position is not recommended. This position can exacerbate supine hypotensive syndrome, which occurs when the gravid uterus compresses the inferior vena cava, reducing venous return and cardiac output. A side-lying position would be more appropriate.
Choice D rationale:
Obtaining a type and crossmatch is crucial. The client’s symptoms suggest a possible placental abruption, which can lead to significant blood loss. Having blood available for transfusion can be lifesaving.
Choice E rationale:
Measuring blood loss by weighing pads can provide an objective assessment of blood loss. This can help guide treatment decisions, including the need for blood transfusion.
Choice F rationale:
Inserting a large-bore IV catheter is necessary in this situation. It allows for rapid fluid and blood replacement if needed. Given the client’s symptoms and the potential for significant blood loss with placental abruption, this intervention is appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Placing the client's arms raised above her head with her legs elevated on pillows (choice A) is not the correct position for a lumbar puncture. This position does not facilitate proper alignment of the spine and may hinder the procedure.
Choice B rationale:
The Trendelenburg position with the body in Sims' position (choice B) is not the correct position for a lumbar puncture. This position is not commonly used for lumbar punctures and may not provide the necessary anatomical alignment for a successful procedure.
Choice C rationale:
Placing the client prone with her arms at her side and her legs extended (choice C) is not the appropriate position for a lumbar puncture. This position does not allow for proper access to the lumbar region and may impede the procedure.
Choice D rationale:
The correct position for a lumbar puncture is to have the client flex their head to the chest and pull their knees up to the abdomen (choice D) This position maximizes the space between the lumbar vertebrae, making it easier for the provider to access the subarachnoid space for cerebrospinal fluid collection.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Assigning the client to a negative pressure airflow room is crucial as varicella zoster is highly contagious and can be transmitted through airborne droplets. A negative pressure room helps contain the virus and filters the air, reducing the risk of spread to other patients and healthcare personnel.
Choice B rationale: Administering aspirin is contraindicated in clients with varicella zoster due to the risk of Reye's syndrome, especially in children and adolescents. Aspirin should not be given to children or adolescents with viral infections because it can cause serious complications affecting the liver and brain.
Choice C rationale: Having visitors remain at least 0.91 m (3 feet) away from the client is insufficient. Varicella zoster is highly contagious and requires more stringent airborne precautions, including having visitors wear masks and follow proper hygiene protocols to minimize the risk of transmission.
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