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 B

Explanation

A. Breast cancer is not a contraindication unless the client has other risk factors for bleeding.

B. Recent eye surgery is a contraindication for warfarin because it increases the risk of bleeding in a delicate surgical site.

C. Warfarin is often used after a myocardial infarction to prevent thromboembolic events.

D. Thrombophlebitis is an indication, not a contraindication, for anticoagulation therapy like warfarin.

A. "I will monitor the client's blood glucose level every 8 hours." B. "I will hang a new bag of TPN and IV tubing every 24 hours." C. "I will increase the rate of the TPN infusion to ensure the correct amount is given." D. "I will obtain the client's weight every other day."

Correct Answer is B

Explanation

A. "I will monitor the client’s blood glucose level every 8 hours": Incorrect. Blood glucose should be monitored more frequently, typically every 4-6 hours, due to the risk of hyperglycemia.

B. "I will hang a new bag of TPN and IV tubing every 24 hours": This practice reduces the risk of infection associated with TPN, which is a high-risk therapy.

C. "I will increase the rate of the TPN infusion to ensure the correct amount is given": Incorrect. The TPN infusion rate should not be adjusted without a provider's order, as it can cause hyperglycemia or fluid overload.

D. "I will obtain the client’s weight every other day": Incorrect. Daily weights are necessary to monitor fluid status and nutritional effectiveness.

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

Nursing Test Bank

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A nurse is caring for a client.

Exhibits

Select the 2 actions that the nurse should take.