Exhibits
The client is at risk of developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Rationale for Correct Choices:
Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.
Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.
Rationale for Incorrect Choices:
Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.
Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.
Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.
Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Uncapped sharps are put in a puncture-resistant container: Proper disposal of sharps in a puncture-resistant container reduces the risk of needlestick injuries and infection. This is a safe practice and does not pose an infection risk to an immunocompromised client.
B. Dampened cloths are used for dusting the area: Using dampened cloths for dusting helps prevent airborne particles from spreading, reducing the risk of inhaling harmful pathogens. This method is considered appropriate for infection control.
C. Waste containers are lined with single bags: Using single-lined waste containers is a standard infection control practice that helps contain biohazardous waste properly. It does not pose a significant infection risk when handled correctly.
D. Soiled linens are placed on the floor: Placing soiled linens on the floor increases the risk of contaminating the environment with pathogens, which can be dangerous for an immunocompromised client. Linens should be placed in designated hampers immediately to prevent cross-contamination and the spread of infections.
Correct Answer is C
Explanation
A. Obtain written consent by the client for the placement of the restraints. It is not typically required to obtain written consent from the client for the use of restraints. However, consent may be necessary for treatment in general, depending on the facility's policies and state laws. Restraints are usually applied to ensure safety and must be justified based on the client's behavior.
B. Release the client's restraints every 4 hr. Restraints should be released more frequently, typically every 1 to 2 hours, to assess the client's safety and physical condition and to allow for movement, hydration, and toileting as appropriate.
C. Document the client's behavior leading to the initiation of the restraints. Documenting the client's behavior that necessitated the use of restraints is crucial for legal and ethical reasons. This documentation provides a clear rationale for the use of restraints and helps ensure compliance with facility policies and regulations.
D. Check the client's status every hour. The client's status should be checked more frequently than every hour. Regular monitoring is essential to ensure the client's safety, comfort, and physical well-being while in restraints. The nurse should assess the client every 15 to 30 minutes based on facility protocols.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.