The nurse is caring for a primigravida at 36-weeks gestation admitted with suspected partial placental abruption. What actions will the nurse implement? Select all that apply.

Place the patient in a supine position.

Encourage oral intake.

Administer IV fluids as indicated.

Evaluate fatal heart rate monitoring.

Monitor maternal pain.

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Placing the patient in a supine position is not recommended in cases of suspected partial placental abruption. The supine position can compress the inferior vena cava, reducing blood flow to the placenta and potentially worsening the condition. Instead, a lateral position is generally preferred to enhance blood flow.

Choice B reason: Encouraging oral intake is not a priority action in this scenario. In cases of suspected placental abruption, the patient may need to undergo emergency medical procedures, and maintaining an empty stomach is often advised to prevent aspiration if anaesthesia is required.

Choice C reason: Administering IV fluids is crucial in managing suspected partial placental abruption. This intervention helps maintain maternal blood pressure and ensures adequate blood flow to the placenta, which is essential for fatal well-being. IV fluids can also be vital in managing any potential blood loss.

Choice D reason: Evaluating fatal heart rate monitoring is essential to assess the foetus’s well-being. Continuous monitoring allows the healthcare team to detect any signs of fatal distress, which can guide further medical interventions and decision-making processes.

Choice E reason: Monitoring maternal pain is a critical component of managing suspected partial placental abruption. Pain assessment helps determine the severity of the abruption and the effectiveness of pain management strategies. It also provides valuable information about the patient's condition and the need for additional interventions.

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Correct Answer is C

Explanation

Choice A reason: Observing for mental confusion or hallucinations is important, but it is not the priority action following myelography. While these symptoms can occur due to complications, they are less common than changes in muscle tone or motor function.

Choice B reason: Assessing motor function is crucial, but the priority is specifically monitoring for changes in muscle tone, such as a decrease in spasticity. Myelography can affect the spinal cord and nerve roots, potentially leading to changes in muscle tone and motor function.

Choice C reason: Monitoring for a decrease in spasticity is the priority nursing action. Myelography involves injecting contrast material into the spinal canal, which can affect the spinal cord and nerve roots. Monitoring for changes in muscle tone, such as a decrease in spasticity, helps detect potential complications early and allows for timely intervention.

Choice D reason: Performing a follow-up MRI is not the immediate priority nursing action. While follow-up imaging may be necessary to assess the results of the myelography, the immediate focus is on monitoring the patient's neurological status and ensuring their safety.

A. The primary care provider will discuss screening for diabetes today. B. You must fast tonight and return in the morning for a one-hour glucose test. C. The primary care provider will recommend that you eliminate sugar from your diet. D. The three-hour glucose tolerance test will be performed today.

Correct Answer is A

Explanation

Choice A reason: Discussing screening for diabetes is appropriate as pre-diabetes in a newly pregnant patient requires careful monitoring and management to prevent the development of gestational diabetes. Early detection and intervention can improve outcomes for both the mother and the baby.

Choice B reason: A one-hour glucose test is typically part of the gestational diabetes screening process, but it is not necessary to fast overnight specifically for the initial discussion and planning. The timing and preparation for specific tests will be guided by the healthcare provider.

Choice C reason: Eliminating sugar from the diet can be part of managing pre-diabetes, but it is not the immediate response to finding pre-diabetes in a newly pregnant patient. A more comprehensive approach will be discussed with the primary care provider.

Choice D reason: A three-hour glucose tolerance test is a diagnostic test for gestational diabetes, which may be recommended later if initial screening results warrant it. It is not typically performed immediately without prior discussion and planning with the healthcare provider.

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The nurse is caring for a primigravida at 36-weeks gestation admitted with suspected partial placental abruption. What actions will the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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