A nurse manager on a labor and delivery unit is discussing care of clients who have vaginal bleeding due to placenta previa with a newly licensed nurse. Which of the following statements should the nurse manager make?
"Administer corticosteroids if the client is at more than 34 weeks of gestation."
"Initiate continuous monitoring of the FHR and uterine contractions."
"Administer terbutaline subcutaneously if the client experiences uterine atony."
"Perform a vaginal exam to determine cervical dilation."
The Correct Answer is B
Choice A rationale:
Administering corticosteroids is relevant for clients at risk of preterm labor, not specifically for placenta previa.
Choice B rationale:
Placenta previa can lead to bleeding and potential fetal distress. Continuous monitoring of fetal heart rate (FHR) and uterine contractions is essential to promptly identify any signs of distress.
Choice C rationale:
Terbutaline is a tocolytic medication used to suppress uterine contractions, and it's not relevant for managing uterine atony associated with placenta previa.
Choice D rationale:
Performing a vaginal exam can further increase the risk of bleeding in cases of placenta previa and is generally contraindicated due to the risk of disturbing the placental site.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.
Choice B rationale:
Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.
Choice C rationale:
Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.
Choice D rationale:
Using the client's name is respectful and helpful, but it is not the priority action in this scenario.
Correct Answer is A
Explanation
Choice A rationale:
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
Choice B rationale:
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Choice C rationale:
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
Choice D rationale:
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
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