A nurse is caring for a client who is at 20 weeks of gestation

Which of the following actions should the nurse plan to take? Select all that apply.

Apply internal fetal monitor.

Prepare client for dilation and curettage with suction

Administer 1 hr glucose tolerance test

Refer client to perinatal loss support group

Provide the client with instructions on medroxyprogesterone therapy.

Administer Rho (D) immune globulin

Answer and Explanation

Correct Answer : B,D,F

A. Apply internal fetal monitor: An internal fetal monitor is used to assess fetal heart rate and contractions in a viable pregnancy. In this case, the client has a molar pregnancy with no viable fetus, so fetal monitoring is not appropriate and provides no clinical benefit.

B. Prepare client for dilation and curettage with suction: Suction dilation and curettage (D&C) is the primary treatment for a molar pregnancy to remove abnormal trophoblastic tissue. Planning for this procedure is essential to prevent complications such as hemorrhage, persistent gestational trophoblastic disease, and infection.

C. Administer 1 hr glucose tolerance test: Glucose screening is not indicated at this time. The client is only 20 weeks gestation and is being managed for a molar pregnancy, not for routine prenatal care or gestational diabetes screening. This test is not a priority.

D. Refer client to perinatal loss support group: A molar pregnancy is considered a pregnancy loss, and the client may experience emotional distress. Referral to a perinatal loss support group provides psychological support and helps the client cope with grief and anxiety associated with this event.

E. Provide the client with instructions on medroxyprogesterone therapy: Medroxyprogesterone therapy is not indicated for managing a molar pregnancy. Contraception may be discussed after treatment, but this is not an immediate priority during acute management of the condition.

F. Administer Rho(D) immune globulin: The client is Rh-negative, and any procedure that may cause fetomaternal hemorrhage, such as D&C, requires administration of Rho(D) immune globulin to prevent isoimmunization in future pregnancies. This is a critical prophylactic intervention in Rh-negative clients.

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Correct Answer is D

Explanation

A. Portable suction: Portable suction is typically needed for clients who have airway clearance difficulties or excessive secretions. Infants with tetralogy of Fallot do not usually require suctioning at home unless another respiratory condition is present, so this equipment is not routinely indicated for discharge planning.

B. Cervical collar: A cervical collar is used for immobilization following trauma or cervical spine instability. There is no association between tetralogy of Fallot and spinal injuries, so this item would not be relevant or expected in the discharge needs of this infant.

C. Hemodialyzer: A hemodialyzer is used for clients requiring dialysis due to renal failure. Tetralogy of Fallot does not involve kidney dysfunction, and infants with this condition do not require dialysis equipment at home, making this option inappropriate.

D. Pulse oximeter: A pulse oximeter allows parents to monitor oxygen saturation levels at home, an essential need for infants with tetralogy of Fallot who are at risk for hypoxemia due to right-to-left shunting. Early detection of drops in oxygen saturation helps families respond promptly to cyanotic spells, making this the most appropriate equipment.

A. Hospice care improves quality of life through palliative care B. Hospice care provides 24-hr, in-home care C. Hospice care is intended to postpone death. D. Hospice care encourages the family to coordinate health care services

Correct Answer is A

Explanation

A. Hospice care improves quality of life through palliative care: Hospice focuses on providing comfort, symptom management, and emotional support for clients with terminal illnesses. The primary goal is enhancing quality of life rather than curing the underlying disease.

B. Hospice care provides 24-hr, in-home care: While hospice offers support and on-call services, it does not guarantee continuous 24-hour in-home care. Family caregivers remain the primary providers of daily care, with hospice staff available for assistance as needed.

C. Hospice care is intended to postpone death: Hospice care is not designed to prolong life but to ensure comfort and dignity at the end of life. Interventions are focused on symptom relief rather than curative treatments.

D. Hospice care encourages the family to coordinate health care services: Hospice staff coordinate care, relieving the family of managing complex medical needs. Families are supported rather than being responsible for coordinating all services themselves.

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A nurse is caring for a client who is at 20 weeks of gestation Which of the following actions should the nurse plan to take? Select all that apply.

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A nurse is caring for a client who is at 20 weeks of gestation

Which of the following actions should the nurse plan to take? Select all that apply.