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. Speak in a normal voice at a natural pace: This allows the interpreter to accurately convey the nurse's message without confusion or misinterpretation. Speaking slowly or loudly is unnecessary and can be perceived as disrespectful.

B. Pause in the middle of sentences: Pausing mid-sentence may result in incomplete or confusing information being relayed to the client.

C. Direct statements to the interpreter: The nurse should direct communication to the client to maintain engagement and respect.

D. Use gestures when speaking with the client: Gestures can be misinterpreted, and relying on them reduces clear verbal communication.

A. Ecchymosis B. Pain level C. Edema D. Sensation

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

Explanation

Assessment Findings	Sprain	Fracture	Dislocation
Ecchymosis	✅	✅	✅
Pain level	✅	✅	✅
Edema	✅	✅	✅
Sensation	✅	✅

Rationale:

Ecchymosis (bruising):

Sprain: Common due to soft tissue damage.

Fracture: Frequently present due to bone and soft tissue injury.

Dislocation: Bruising often accompanies joint dislocation.

Pain level:

Sprain: Moderate pain, often exacerbated by movement.

Fracture: Pain is typically sharp and worsens with movement or weight-bearing.

Dislocation: Severe pain due to misalignment of the joint.

Edema:

Sprain: Common due to inflammation from ligament injury.

Fracture: Swelling is typical around the fracture site.

Dislocation: Edema occurs due to joint misalignment and tissue trauma.

Sensation (tingling):

Sprain: Nerve compression or irritation may cause tingling.

Fracture: Tingling can result from nerve involvement or swelling near the fracture site.

Dislocation: Tingling is less common unless nerve damage occurs, which is more serious and often leads to numbness or motor impairment.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

Explanation

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A nurse is caring for a client.

Exhibits

Select the 2 actions that the nurse should take.