A nurse is caring for a client who is at 32 weeks of gestation.
Administer betamethasone IM
Prepare client for an immediate cesarean birth
Perform vaginal exams every shift
Provide continuous external fetal heart monitoring
Provide the client with instructions about limiting activity
Monitor intake and output
Prepare and transfuse A-positive blood products
Correct Answer : A,D,E,F
Rationale:
A. Administer betamethasone IM to enhance fetal lung maturity in case of preterm delivery (<34 weeks).
B. Immediate cesarean birth is not indicated unless there is heavy bleeding or fetal distress. The client is stable with normal FHR and moderate variability.
C. Vaginal examinations are contraindicated in placenta previa because they can cause placental separation and severe hemorrhage.
D. Continuous external fetal heart monitoring helps assess fetal well-being and detect distress due to bleeding or hypoxia.
E. Activity limitation reduces uterine activity and the risk of further bleeding. The client should avoid sexual activity and strenuous exercise.
F. Monitoring intake and output helps assess renal perfusion, especially if bleeding increases or the client develops hypotension.
G. Transfusing A-positive blood is inappropriate because the client’s type is A-negative; incompatible transfusion would cause hemolytic reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased drainage may indicate bleeding or infection; the nurse should assess and report, not remove the drain.
B. The nurse should monitor patency and drainage flow to ensure suction is functioning and prevent fluid accumulation in the wound bed.
C. Tubing is not routinely changed; it is maintained as a closed sterile system to reduce infection risk.
D. Irrigation is contraindicated in closed systems like a Jackson-Pratt (JP) or Hemovac, as it can break sterility and impair suction.
Correct Answer is B
Explanation
A. Vital signs: The client’s heart rate remains elevated (110–118/min) and orthostatic hypotension persists (BP 116/80 sitting, 88/68 standing), indicating ongoing dehydration and malnutrition. These findings suggest worsening fluid and electrolyte imbalance, not improvement.
B. Client statement: The client’s verbalization, “I want to stop and get better,” reflects acknowledgment of the disorder and readiness for behavioral change, a critical first step in recovery from bulimia nervosa. This statement shows therapeutic progress in the mental health aspect of treatment, demonstrating insight and motivation for recovery. In clients with eating disorders, early progress is typically seen in attitude and cooperation rather than rapid physical recovery.
C. ECG: The ECG continues to show sinus tachycardia with premature ventricular contractions (PVCs), consistent with hypokalemia and cardiac irritability. No improvement in cardiac stability is evident.
D. Electrolytes: Laboratory results show worsening hypokalemia (K⁺ 2.9 mEq/L) and hyponatremia (Na⁺ 130 mEq/L). These indicate increasing severity of electrolyte imbalance, a potentially life-threatening complication.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.