The practical nurse (PN) is assisting the registered nurse (RN) in caring for a client with placenta previa who is at 31-weeks gestation.
Which method should the PN use to most accurately estimate blood loss?
Describe percentage of perineal pads saturated with blood.
Notify the laboratory to obtain an hourly hematocrit.
Evaluate changes in vital signs that might indicate shock.
Calculate the difference in weight of perineal pad before and after use.
The Correct Answer is D
Choice A rationale
Describing the percentage of saturated perineal pads is a subjective and imprecise method for estimating blood loss. Variations in pad size, absorbency, and the client's perception can lead to significant inaccuracies, making it unreliable for precise clinical assessment of hemorrhage.
Choice B rationale
While hematocrit levels are crucial for assessing overall blood volume status, obtaining an hourly hematocrit is an indirect and reactive measure of acute blood loss. It reflects hemodilution or hemoconcentration over time rather than providing a real-time, accurate quantification of the volume of blood lost. Normal hematocrit for pregnant women is 33% to 44%.
Choice C rationale
Changes in vital signs, such as tachycardia, hypotension, and tachypnea, are late indicators of significant blood loss and hypovolemic shock. Relying solely on vital signs means that a substantial amount of blood has already been lost before changes become apparent, making it an insensitive method for early detection and estimation.
Choice D rationale
Calculating the difference in weight of perineal pads before and after use provides a highly accurate objective measurement of blood loss. One gram of weight is approximately equivalent to one milliliter of blood, allowing for precise quantification and enabling timely and appropriate clinical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.3"]
Explanation
Step 1 is to convert the child's weight from pounds to kilograms. 66 pounds ÷ 2.2 pounds/kg = 30 kg.
Step 2 is to calculate the total dose in milligrams. 0.01 mg/kg × 30 kg = 0.3 mg.
Step 3 is to calculate the volume to administer in milliliters. 0.3 mg ÷ (1 mg/mL) = 0.3 mL.
Correct Answer is ["C","D"]
Explanation
Choice A rationale
Pink-tinged urine can be a symptom of various conditions, including kidney issues or urinary tract infections. While individuals with sickle cell crisis can experience kidney complications, pink-tinged urine is not a universal or primary manifestation of a vaso-occlusive crisis. The immediate priority is pain management and infection prevention.
Choice B rationale
Palpitations, an awareness of one's own heartbeat, can be a symptom of various cardiac issues or a physiological response to stress or pain. While the heart rate is elevated (140 bpm, normal for a toddler is 90-140 bpm), this is likely secondary to the severe pain the child is experiencing and not the primary problem to be addressed.
Choice C rationale
Acute pain is a hallmark and often excruciating symptom of a sickle cell crisis, resulting from vaso-occlusion and tissue ischemia. The toddler's crying, restlessness, and aversion to touch strongly indicate severe pain, making it an immediate priority for intervention to alleviate suffering and prevent further complications.
Choice D rationale
Risk for infection is a significant concern in sickle cell disease due to functional asplenia, which compromises the immune system's ability to fight encapsulated bacteria. Despite the normal oxygen saturation, the elevated temperature (102°F or 38.8°C) in a child with sickle cell disease warrants immediate attention due to the high risk of severe infection.
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.