A nurse is caring for a client who is at risk for developing intraventricular hemorrhage (IVH).

Which action should the nurse take to reduce the client's risk?

Encouraging early ambulation

Administering medications to induce hypercoagulability

Monitoring the client's blood glucose levels

Maintaining a neutral head position

Answer and Explanation

The Correct Answer is D

Maintaining a neutral head position. This action can help reduce the client’s risk of intraventricular hemorrhage (IVH) by preventing fluctuations in intracranial pressure that could rupture blood vessels in the brain.

Choice A is wrong because encouraging early ambulation can increase the risk of IVH by causing changes in blood pressure and cerebral perfusion.

Choice B is wrong because administering medications to induce hypercoagulability can increase the risk of IVH by promoting thrombosis and impairing blood flow to the brain.

Choice C is wrong because monitoring the client’s blood glucose levels is not directly related to the prevention of IVH, although it may be important for other reasons such as avoiding hypoglycemia or hyperglycemia.

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Correct Answer is B

Explanation

Monitoring cervical changes.

This is because cervical changes indicate the progress of labor and the risk of preterm delivery.

Preterm labor is defined as regular uterine contractions with cervical dilation and effacement before 37 weeks of gestation.

The nurse should assess the cervical length, dilation, effacement, and position frequently to determine the need for interventions to stop or delay labor.

Choice A is wrong because monitoring vital signs is not specific to fetal well-being.

Vital signs can reflect maternal health, infection, or complications, but they do not directly measure fetal status.

Choice C is wrong because monitoring fluid intake and output is not specific to fetal well-being.

Fluid balance can affect maternal hydration, electrolytes, and blood pressure, but it does not directly measure fetal status.

Choice D is wrong because monitoring maternal preference is not specific to fetal well-being.

Maternal preference can affect the comfort, satisfaction, and coping of the mother, but it does not directly measure fetal status.

A. Fetal heart rate of 150/min B. Fetal heart rate variability of 10/min C. Fetal heart rate decelerations D. Fetal heart rate accelerations

Correct Answer is C

Explanation

Fetal heart rate decelerations indicate fetal distress because they reflect a decrease in blood flow or oxygen to the fetus.

Choice A is wrong because a fetal heart rate of 150/min is within the normal range of 110-160 bpm.Choice B is wrong because a fetal heart rate variability of 10/min is considered moderate and reassuring.Choice D is wrong because fetal heart rate accelerations are a sign of fetal well-being and indicate that the fetus is responding to stimuli.

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A nurse is caring for a client who is at risk for developing intraventricular hemorrhage (IVH). Which action should the nurse take to reduce the client's risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a client who is at risk for developing intraventricular hemorrhage (IVH). Which action should the nurse take to reduce the client's risk?

A nurse is caring for a client who is at risk for developing intraventricular hemorrhage (IVH).

Which action should the nurse take to reduce the client's risk?