A nurse is caring for a client.

Exhibits

Select the 2 actions that the nurse should take.

Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP)

Obtain serial H&H and clotting studies.

Administer misoprostol 600 mg rectally.

Place the client in a supine position.

Prepare to transfuse 2 units of packed RBCs.

Answer and Explanation

Correct Answer : A,E

A. Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP): This action is not the priority in the context of the client's current clinical status, particularly with the risk of placental abruption and severe bleeding. Fetal monitoring via scalp electrode and IUCP is typically reserved for stable clients, and invasive monitoring should be avoided in a potentially unstable situation.

B. Obtain serial H&H and clotting studies: The client is presenting with significant vaginal bleeding, low hemoglobin (8.1 g/dL at 0930, decreased to 7.5 g/dL at 1005), and low hematocrit levels (24% at 0930, dropping to 21% at 1005). Serial hemoglobin and hematocrit levels will help monitor ongoing blood loss and guide decisions regarding further interventions, such as transfusion. Clotting studies, including the prothrombin time and PTT, are necessary to assess the client's coagulation status and potential for disseminated intravascular coagulation (DIC), which can be associated with placental abruption or severe bleeding.

C. Administer misoprostol 600 mg rectally: Misoprostol is used to manage postpartum hemorrhage or to induce labor, but it is not indicated in the acute management of this client's condition. The client is 38 weeks gestation and presenting with signs of potential placental abruption, not requiring the use of misoprostol at this time.

D. Place the client in a supine position: The client should not be placed in a supine position, as this may exacerbate hypotension due to the supine hypotension syndrome, particularly if the uterus is compressing the inferior vena cava. The client would benefit more from positioning that promotes circulation, such as lying on the left side.

E. Prepare to transfuse 2 units of packed RBCs: The client is showing signs of hypovolemic shock with progressively declining blood pressure (from 95/62 mm Hg to 85/48 mm Hg), elevated heart rate (from 104/min to 128/min), and worsening hematocrit and hemoglobin. Blood transfusion is likely necessary to restore circulating volume, improve oxygen delivery, and address the ongoing blood loss.

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Correct Answer is A

Explanation

A. Ensuring the client has an alert system addresses immediate safety and the risk of falls, which is a priority for a client with mobility impairments.

B. Support groups are beneficial for emotional support but are secondary to physical safety.

C. Transportation resources are important but do not address the urgent need for fall prevention.

D. Home physical therapy is important for recovery but does not immediately ensure the client's safety.

A. "Take your temperature every night before going to bed." B. "Take your temperature 1 hour after getting out of bed." C. "Take your temperature immediately after waking and before getting out of bed." D. "Take your temperature within 30 minutes after your first morning void."

Correct Answer is C

Explanation

A. Take your temperature every night before going to bed: Nighttime readings are not basal body temperatures.

B. Take your temperature 1 hour after getting out of bed: This does not reflect the true basal temperature.

C. Take your temperature immediately after waking and before getting out of bed: This ensures an accurate basal temperature, as any activity can alter the reading.

D. Take your temperature within 30 minutes after your first morning void: BBT should be measured before any activity, including voiding.

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A nurse is caring for a client. Exhibits Select the 2 actions that the nurse should take.

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A nurse is caring for a client.

Exhibits

Select the 2 actions that the nurse should take.