A woman is about to undergo an external version. What action by the nurse takes priority?
A.
Determine Rh status; give Rh immune globulin if needed.
B.
Explain the procedure to the woman and obtain consent.
C.
Offer emotional support to both the woman and her partner.
D.
Prepare to administer oxytocin (Pitocin) as per protocol.
ANS: A
Because the version can cause feto-maternal bleeding, women who are Rh-negative should receive Rh immune globulin (RhoGAM). Offering emotional support is always important, but does not take priority over keeping the patient safe. The physician is responsible for explaining the procedure. Because uterine relaxation is important for a successful version, tocolytic medications may be given (not medications that increase uterine tone).
You might also like to view...
The client enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts."
The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks. Based on this data, which diagnosis does the nurse anticipate? A) Systemic lupus erythematosus B) Fibromyalgia C) Lyme disease D) Gout
The newly hired nurse notices that co-workers routinely pray with clients and their families. The nurse has never been particularly religious or spiritual, and is unaccustomed to praying, but holds no strong feeling against prayer
What is the best strategy for the nurse to plan for such situations? A) Memorize two or three short, formal prayers to use when prayer is requested. B) Arrange to have a co-worker substitute for the nurse in these prayer situations. C) Try to ensure assignment to clients who are unlikely to request prayer. D) Just stand silently at the bedside and let others in the room do the praying.
A nurse is examining a 2-year-old child diagnosed with ataxic cerebral palsy. The child is unable to perform fine leg movements and has a wide-based gait. What other distinguishing features should the nurse look for in this client?
A) Problems with depth perception B) Writhing involuntary movements C) Evidence of full or partial paralysis D) Increased muscle tone or spasticity
The nurse is reviewing the laboratory reports for a client with chronic kidney failure. Which lab should the nurse understand reflects the progression of the kidney disease?
A. Glomerular filtration rate (GFR) B. Serum creatinine C. Blood urea nitrogen (BUN) D. Urinalysis