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:
A high-protein diet might not be recommended for a client with chronic pancreatitis, as certain high-protein foods can exacerbate symptoms.
Choice B Rationale:
Encouraging the client to eat high-fiber foods can help manage symptoms of chronic pancreatitis, as well as promote regular bowel movements and prevent constipation.
Choice C rationale:
Administering laxatives daily is not typically part of the management plan for chronic pancreatitis and can lead to dependency.
Choice D rationale:
Providing six small meals per day might be helpful, but the specific dietary content is important for managing chronic pancreatitis.
Correct Answer is C
Explanation
Choice A rationale:
Scheduling appointments earlier in the day accommodates the client's potential "on" periods when Parkinson's symptoms are better controlled.
Choice B rationale:
Looking down at the feet while walking is a technique that can help improve gait and stability, as Parkinson's disease often affects balance.
Choice C rationale:
Thicker liquids are less likely to cause aspiration in individuals with Parkinson's disease, as they can have difficulty coordinating the muscles needed for swallowing.
Choice D rationale:
Constipation is a common issue in Parkinson's disease due to decreased gastrointestinal motility. However, focusing on dietary fiber and fluid intake is preferred before considering laxatives.
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