A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
Administer oxygen via nasal cannula.
Offer option to view products of conception.
Instruct the client to increase potassium-rich foods in the diet.
Maintain the client in a Trendelenburg position.
The Correct Answer is B
Choice A reason: Administering oxygen via nasal cannula is not a necessary intervention for the client, unless she has signs of hypoxia, such as dyspnea, tachypnea, or cyanosis. Oxygen administration is not routinely indicated for clients with inevitable abortion.
Choice B reason: Offering option to view products of conception is an appropriate intervention for the client, because it can help her cope with the loss of pregnancy and facilitate the grieving process. The nurse should respect the client's decision and provide emotional support.
Choice C reason: Instructing the client to increase potassium-rich foods in the diet is not a relevant intervention for the client, unless she has signs of hypokalemia, such as muscle weakness, cramps, or arrhythmias. Potassium intake is not related to the cause or prevention of inevitable abortion.
Choice D reason: Maintaining the client in a Trendelenburg position is not a recommended intervention for the client, because it can increase the risk of aspiration, respiratory compromise, and venous congestion. Trendelenburg position is not effective in preventing or treating inevitable abortion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Prostaglandin E2 is not an appropriate medication for the client, because it is a uterotonic agent that stimulates uterine contractions and cervical ripening. Prostaglandin E2 is used to induce labor, not to stop it.
Choice B reason: Methylergonovine is not an appropriate medication for the client, because it is a uterotonic agent that causes sustained uterine contractions and vasoconstriction. Methylergonovine is used to prevent or treat postpartum hemorrhage, not to stop preterm labor.
Choice C reason: Terbutaline is an appropriate medication for the client, because it is a tocolytic agent that relaxes the uterine smooth muscle and inhibits contractions. Terbutaline is used to delay preterm labor and prolong pregnancy.
Choice D reason: Oxytocin is not an appropriate medication for the client, because it is a uterotonic agent that stimulates uterine contractions and milk ejection. Oxytocin is used to augment labor, not to stop it.
Correct Answer is A
Explanation
Choice A reason: The mother applying lotion to the newborn's skin requires intervention by the nurse, because it can interfere with the effectiveness of phototherapy and increase the risk of thermal injury. The nurse should instruct the mother to avoid using any lotions, creams, or oils on the newborn's skin during phototherapy.
Choice B reason: The newborn's stools increasing in number does not require intervention by the nurse, because it is a normal and expected outcome of phototherapy. Phototherapy can increase the breakdown and excretion of bilirubin, which can result in more frequent and loose stools.
Choice C reason: A pink rash appearing on the newborn's trunk does not require intervention by the nurse, because it is a common and harmless side effect of phototherapy. The rash usually disappears within a few days after phototherapy is discontinued.
Choice D reason: The newborn's eyes being covered with a mask does not require intervention by the nurse, because it is a standard and essential precaution for phototherapy. The mask protects the newborn's eyes from the harmful effects of the light, such as corneal damage or retinal injury.
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