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

Administering tocolytics.Tocolytics are drugs that inhibit uterine contractions and can delay preterm labor for a short time.This can allow time for the administration of corticosteroids and transfer to a tertiary care facility if necessary.

Choice A is wrong because administering intravenous fluids does not reduce uterine activity.It may be used to correct dehydration or electrolyte imbalance, which can be risk factors for preterm labor.

Choice C is wrong because administering corticosteroids does not reduce uterine activity.It may be used to enhance fetal lung maturity and reduce the risk of neonatal complications such as respiratory distress syndrome, intracranial hemorrhage, and necrotizing enterocolitis.

Choice D is wrong because administering antibiotics does not reduce uterine activity.It may be used to treat infections that can trigger preterm labor, such as bacterial vaginosis or chorioamnionitis.

A. Administering intravenous fluids B. Administering tocolytics C. Administering corticosteroids D. Providing emotional support

Correct Answer is B

Explanation

The correct answer is choice B. Administering tocolytics.Tocolytics are drugs that inhibit uterine contractions and can delay preterm labor for a short time.This can allow time for the administration of antenatal corticosteroids and transfer to a tertiary care facility if necessary.

Choice A is wrong because administering intravenous fluids does not improve blood flow to the placenta and fetus.It may also increase the risk of pulmonary edema in women with preterm labor.

Choice C is wrong because administering corticosteroids does not improve blood flow to the placenta and fetus.Corticosteroids are given to enhance fetal lung maturity and reduce the risk of neonatal complications such as respiratory distress syndrome, intracranial hemorrhage, and necrotizing enterocolitis.

However, they do not stop preterm labor.

Choice D is wrong because providing emotional support does not improve blood flow to the placenta and fetus.Emotional support is important for women with preterm labor, but it is not a priority intervention to prevent fetal hypoxia or acidosis.

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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

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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?