Nokea
A pregnant client at 32 weeks' gestation is admitted to the obstetrical unit for observation after a motor vehicle crash. When the client begins experiencing slight vaginal bleeding and mild cramps, which action should the nurse take to support the viability of the fetus?
- A. Insert an intravenous line and begin an infusion at 125 mL per hour.
- B. Administer oxygen to the woman via a face mask at 7 to 10 L per minute.
- C. Position and connect the ultrasound transducer to the external fetal monitor.
- D. Position and connect a spiral electrode to the fetal monitor for internal fetal monitoring.
Correct Answer: C
Rationale: External fetal monitoring will allow the nurse to determine any change in the fetal heart rate and rhythm that would indicate that the fetus is in jeopardy. The amount of bleeding described is insufficient to require intravenous fluid replacement. Because fetal distress has not been determined at this time, oxygen administration is premature. Internal monitoring is contraindicated when there is vaginal bleeding, especially in preterm labor.
You may also like to solve these questions
A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which nursing assessment findings are associated with this form of heart disease? Select all that apply.
- A. Fever
- B. Leukopenia
- C. Bradycardia
- D. Pericardial friction rub
- E. Decreased erythrocyte sedimentation rate
- F. Precordial chest pain that intensifies by the supine position
Correct Answer: A,D,F
Rationale: In acute bacterial pericarditis, the membranes surrounding the heart become inflamed and rub against each other, producing the classic pericardial friction rub. Fever typically occurs and is accompanied by leukocytosis and an elevated erythrocyte sedimentation rate. The client complains of severe precordial chest pain that intensifies when lying supine and decreases in a sitting position. The pain also intensifies when the client breathes deeply. Malaise, myalgia, and tachycardia are common.
The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
- A. Do you have tremors in your hands?
- B. Are you experiencing pain in your joints?
- C. Have you had problems with diarrhea lately?
- D. Do you notice any swelling in your legs at night?
Correct Answer: B
Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain and pathological fractures. Options 1 and 3 relate to assessment of hypoparathyroidism. Option 4 is unrelated to hyperparathyroidism.
Twelve hours after delivery, the nurse assesses the client for uterine involution. The nurse determines that the uterus is progressing normally toward its prepregnancy state when palpation of the client's fundus is at which level?
- A. At the umbilicus
- B. One finger breadth below the umbilicus
- C. Two finger breadths below the umbilicus
- D. Midway between the umbilicus and the symphysis pubis
Correct Answer: A
Rationale: The term 'involution' is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its nonpregnant state. Immediately after the delivery of the placenta, the uterus contracts to the size of a large grapefruit. The fundus is situated in the midline between the symphysis pubis and the umbilicus. Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one finger breadth on each succeeding day.
A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. Which expected prescription should the nurse immediately implement for this client? Select all that apply.
- A. Supplemental oxygen
- B. High Fowler's position
- C. Semi-Fowler's position
- D. Morphine sulfate intravenously
- E. Two tablets of acetaminophen with codeine
- F. Meperidine hydrochloride intravenously
Correct Answer: A,C,D
Rationale: Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.
The nurse caring for a client receiving intravenous therapy monitors for which signs of infiltration of an intravenous (IV) infusion? Select all that apply.
- A. Slowing of the IV rate
- B. Tenderness at the insertion site
- C. Edema around the insertion site
- D. Skin tightness at the insertion site
- E. Warmth of skin at the insertion site
- F. Fluid leaking from the insertion site
Correct Answer: A,B,C,D,F
Rationale: Infiltration is the leakage of an IV solution into the extravascular tissue. Manifestations include slowing of the IV rate; burning, tenderness, or general discomfort at the insertion site; increasing edema in or around the catheter insertion site; complaints of skin tightness; blanching or coolness of the skin; and fluid leaking from the insertion site.