A nurse is planning care for a client who is experiencing moderate vaginal bleeding due to a placental abruption. Which of the following interventions should the nurse include in the plan?
Check cervical dilation every 2 hr.
Initiate an IV with an 18-gauge catheter.
Monitor FHR hourly.
Obtain vital signs every 4 hr.
The Correct Answer is B
Choice A rationale:
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
Choice B rationale:
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
Choice C rationale:
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
Choice D rationale:
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
High-impact exercises might not be suitable for all clients and could potentially exacerbate symptoms such as joint pain or discomfort.
Choice B rationale:
Menopause is confirmed after 12 consecutive months without a menstrual period. Until this point, there is still a risk of pregnancy, and contraceptive measures should be used.
Choice C rationale:
Pelvic muscle exercises (Kegel exercises) are important for strengthening pelvic floor muscles but are not specifically related to menopause.
Choice D rationale:
Using a water-based lubricant for painful vaginal intercourse is a helpful suggestion, but it is not the primary focus of menopause education.
Correct Answer is C
Explanation
Choice A rationale:
Asterixis is a hand-flapping tremor that can be associated with hepatic encephalopathy, not pancreatic cancer.
Choice B rationale:
Weight gain is not typically associated with pancreatic cancer and may not be a relevant manifestation to include.
Choice C rationale:
Abdominal pain is a common manifestation of pancreatic cancer and should be included in the teaching.
Choice D rationale:
Constipation is not typically associated with pancreatic cancer and may not be a relevant manifestation to include.
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