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 {"A":{"answers":"A"},"B":{"answers":"B,C"},"C":{"answers":"B,C"},"D":{"answers":"B,C"},"E":{"answers":"B,C"},"F":{"answers":"A"}}
Explanation
|
Condition |
Definition |
Causes |
Symptoms |
Treatment |
|
Agranulocytosis |
A severe and potentially life-threatening reduction in the number of white blood cells (neutrophils) that fight infection. |
Can be caused by some antipsychotic medications, such as clozapine, olanzapine, and quetiapine. |
Sore throat, fever, chills, mouth ulcers, infections, bleeding, and fatigue. |
Discontinuation of the offending medication, antibiotics, antifungals, and granulocyte colony-stimulating factor (G-CSF) injections to stimulate the bone marrow to produce more white blood cells. |
|
Neuroleptic Malignant Syndrome (NMS) |
A rare but serious reaction to antipsychotic medications, especially the older ones, such as haloperidol, fluphenazine, and chlorpromazine. |
Can be triggered by high doses, rapid dose changes, or switching of antipsychotic medications. |
High fever, muscle rigidity, altered mental status, autonomic instability (blood pressure changes, tachycardia, sweating, etc.), and elevated creatine kinase levels. |
Discontinuation of the offending medication, supportive care, cooling measures, hydration, and medications such as dantrolene, bromocriptine, or amantadine to counteract the effects of dopamine blockade. |
|
Serotonin Syndrome |
A potentially life-threatening condition caused by excessive levels of serotonin in the brain. |
Can be caused by taking too much of a serotonin-enhancing medication, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), or other drugs that affect serotonin levels, such as tramadol, linezolid, or St. John’s wort. Can also be caused by combining two or more serotonin-enhancing medications. |
Agitation, confusion, disorientation, anxiety, hallucinations, muscle spasms, tremors, shivering, hyperreflexia, incoordination, diarrhea, nausea, vomiting, blood pressure changes, tachycardia, and hyperthermia. |
Discontinuation of the offending medication(s), supportive care, hydration, and medications such as benzodiazepines, cyproheptadine, or serotonin antagonists to reduce serotonin levels. |
Correct Answer is C
Explanation
Choice A rationale:
Tilt your head forward while inhaling is not an appropriate instruction for using an albuterol metered-dose inhaler (MDI) In fact, it is recommended to keep the head in a neutral position while using an MDI to ensure proper delivery of the medication to the lungs. Tilted head positions can lead to ineffective inhalation and may result in the medication being deposited in the mouth or throat rather than reaching the lungs. Therefore, choice A is not the correct answer.
Choice B rationale:
Exhale immediately after inhaling is not an accurate instruction for using an albuterol MDI. The correct sequence is to inhale slowly and deeply through the mouth while pressing down on the canister to release the medication, hold the breath for a few seconds (usually 10 seconds), and then exhale slowly. Exhaling immediately after inhaling would not allow the medication to reach the lower airways effectively. Therefore, choice B is not the correct answer.
Choice C rationale:
"Close your mouth around the mouthpiece" is an essential instruction for using an albuterol MDI correctly. It ensures that the medication
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