The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.
The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Repeat quantitative B-hCG level
Methotrexate IM
Blood typing
Cervical cerclage
Transvaginal ultrasound
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"}}
• Repeat quantitative B-hCG level: Monitoring the trend of quantitative beta-hCG levels is crucial in suspected ectopic pregnancy. Falling or plateauing hCG levels confirm the diagnosis and guide the management plan, especially if methotrexate is administered or surgical intervention is considered.
• Methotrexate IM: Methotrexate is an anticipated prescription for the medical management of a stable ectopic pregnancy. It works by stopping the growth of rapidly dividing cells and is appropriate when the client is hemodynamically stable and the ectopic pregnancy is unruptured.
• Blood typing: Blood typing is essential to determine Rh factor status. If the client is Rh-negative, Rh immune globulin should be administered to prevent isoimmunization, which could impact future pregnancies. This is a standard part of the care plan for any pregnancy loss or threatened pregnancy complication.
• Transvaginal ultrasound: A transvaginal ultrasound is needed to confirm the location of the pregnancy. In ectopic pregnancies, it helps visualize the presence or absence of an intrauterine gestational sac and may directly identify ectopic implantation, such as in the fallopian tube.
• Cervical cerclage: Cervical cerclage is contraindicated in this case. It is used to prevent preterm birth in clients with cervical insufficiency but is not appropriate in a non-viable pregnancy or suspected ectopic pregnancy. Placing a cerclage could worsen the clinical situation and delay necessary treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will ask to have you assigned to a female nurse.": Respecting the client’s preference supports her autonomy, comfort, and dignity. Offering to accommodate her request shows sensitivity to her personal, cultural, or religious needs and helps maintain a trusting nurse-client relationship.
B. "I will get a female assistive personnel to provide your bath.": While providing a female assistive personnel for bathing might address part of the concern, it does not fully meet the client's expressed preference for all aspects of nursing care to be provided by a female nurse.
C. "You will need to speak with the nurse manager about this.": Asking the client to manage the reassignment request herself can seem dismissive. It is the nurse’s responsibility to advocate for the client and initiate steps to meet her needs whenever possible.
D. "I care for other female clients and they do not mind having a male nurse.": Comparing the client’s feelings to those of others invalidates her concerns and does not demonstrate respect for her individual preferences, which is essential in client-centered care.
Correct Answer is C
Explanation
A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.
B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.
C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.
D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.
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