A client who has a diagnosis of complete placenta previa is admitted to the labor and
delivery suite at 36 weeks gestation with contractions 5 minutes in frequency and 1 minute in duration. Which of the following actions should the nurse take?
Rupture the amniotic sac.
Medicate the client for pain.
Prepare the client for a cesarean section.
Perform a vaginal exam.
The Correct Answer is C
A. Rupturing the amniotic sac in the case of complete placenta previa can lead to significant bleeding and is contraindicated.
B. Pain medication may be administered if needed, but the priority is to address the placenta previa and potential complications.
C. Complete placenta previa at 36 weeks gestation with contractions and bleeding is a clear
indication for an emergency cesarean section to prevent maternal hemorrhage and fetal distress.
D. Performing a vaginal exam can increase the risk of bleeding and should be avoided in cases of placenta previa.
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Related Questions
Correct Answer is D
Explanation
A. Irregular uterine contractions at 38 weeks of gestation may not be a concern unless they become regular and more intense.
B. A client scheduled for a nonstress test (NST) at 39 weeks of gestation can typically wait until after attending to more urgent matters.
C. A client scheduled for an induction of labor at 40 weeks of gestation is not necessarily a priority unless there are urgent concerns.
D. Decreased fetal movement, especially for 2 days at 36 weeks of gestation, requires immediate assessment to ensure fetal well-being.
Correct Answer is A
Explanation
A.
A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop
the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.
B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.
C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.
D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.
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