The nurse is caring for a client who is diagnosed with abruptio placentae based on the client's history, physical examination, and laboratory studies. What nursing interventions should be initiated immediately?
A) Continuously monitor the fetus even if a fetal heart rate is not present.
B) Identify the lower limit of the fundus and mark it on the woman's abdomen.
C) Observe the fundus for changes in shape or movement upward.
D) Monitor and report decrease in, or movement downward, of abdominal girth.
C
Feedback:
The nurse should observe the fundus for changes in shape or movement upward, continuously monitor the fetus if a fetal heart rate is present, identify the upper limit of the fundus and mark it on the woman's abdomen with a felt-tip pen, and measure abdominal girth (the distance around) with a flexible tape measure. If the abdomen increases in girth or moves upward, blood may be collecting within the uterus; this dangerous situation usually calls for immediate cesarean delivery.
You might also like to view...
The nurse would assess that a patient is severely neutropenic if the absolute neutrophil count is less than ______ cells per cubic millimeter
Fill in the blank(s) with correct word
The physician orders potassium chloride (KCL) for the patient who has a nasogastric (NG) tube. What will the nurse plan to do prior to the administration of this drug?
1. Dilute the drug prior to administration through the nasogastric (NG) tube. 2. Flush the nasogastric (NG) tube with Coca-Cola before and after administration. 3. Flush the nasogastric (NG) tube with normal saline before and after administration. 4. There is no particular preparation prior to administration.
Leadership
a. Can be learned b. Cannot be learned c. Is about mutual influence d. Is one-way influence
A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first?
A. Administration of normal saline solution B. Administration of an intravenous (IV) glucocorticoid C. Administration of pain medication to relieve the client's headache D. Administration of a subcutaneous injection of epinephrine (Adrenalin)