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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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Epinephrine auto-injectors should be stored at room temperature and protected from light. Refrigeration is not recommended.
Choice B rationale:
The solution in an epinephrine auto-injector should be clear. If it appears discolored or contains particles, it may be expired or compromised.
Choice C rationale:
Epinephrine auto-injectors should not be shaken before use, as shaking could cause the solution to foam and result in inaccurate dosing.
Choice D rationale:
Holding the epinephrine auto-injector in place for 10 seconds allows the medication to be fully delivered into the muscle, enhancing its effectiveness.
Correct Answer is D
Explanation
Choice A rationale:
Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.
Choice B rationale:
Instructing the client on stress management techniques is important, but safety comes first.
Choice C rationale:
Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.
Choice D rationale:
Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.
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