A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and has heavy, red vaginal bleeding without contractions, that started spontaneously. She is in no distress and states that she can "feel the baby moving.”. The client should undergo an ultrasound to determine which of the following findings?
Rh incompatibility.
Frequency and duration of contractions.
Fetal lung maturity.
Location of the placenta.
The Correct Answer is D
Choice A rationale:
Rh incompatibility is not relevant in this scenario. Rh incompatibility refers to a condition where the mother's blood is Rh-negative, and the baby's blood is Rh-positive, which can lead to hemolytic disease of the newborn. However, this condition is unrelated to the client's current presentation of heavy, red vaginal bleeding without contractions.
Choice B rationale:
Frequency and duration of contractions are not the primary concern in this situation. The client's main complaint is heavy vaginal bleeding without contractions, which indicates a potential issue with the placenta or other pregnancy-related problems.
Choice C rationale:
Fetal lung maturity is not the priority at this stage. The client is at 38 weeks of gestation, which is considered full term. Fetal lung maturity is typically assessed if there's a need for early delivery, which is not indicated in this scenario.
Choice D rationale:
The correct choice. The client is experiencing heavy, red vaginal bleeding, which may be a sign of placental abruption, where the placenta separates from the uterine wall prematurely. Determining the location of the placenta through an ultrasound can help identify if placental abruption is the cause of bleeding. Placental abruption can be a serious condition that requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should recommend the client to increase cellulose and fluid in the diet. Cellulose is a type of fiber found in fruits, vegetables, and whole grains. Increasing fiber intake can help alleviate constipation by adding bulk to the stool and promoting regular bowel movements. Additionally, the recommendation to increase fluid intake complements the effect of fiber, as it softens the stool, making it easier to pass through the intestines. This combination of increased cellulose and fluid intake is a safe and natural way to address constipation during pregnancy without the need for medication or invasive interventions.
Choice B rationale:
Regular use of glycerine suppositories is not the best recommendation for pregnant clients experiencing constipation. Suppositories are inserted into the rectum to stimulate bowel movements and should only be used sparingly when other methods have failed. Pregnant individuals may have increased sensitivity, and it's essential to avoid unnecessary procedures or potential discomfort.
Choice C rationale:
Regular use of a laxative is also not the most suitable recommendation for a pregnant client with constipation. While laxatives can provide relief, they may lead to dependency and might have adverse effects on the developing fetus. It is best to explore safer and more natural methods before resorting to laxative use during pregnancy.
Choice D rationale:
Maintenance of good posture is essential during pregnancy for various rationales, but it is not a specific solution for constipation. While maintaining good posture can help alleviate back pain and other discomforts, it does not directly address the issue of constipation.
Correct Answer is D
Explanation
The correct answer is choice D. Uterine contraction lasting 2 min.
Choice A rationale:
Early decelerations in the FHR are usually not a concern during the second stage of labor. They are a normal physiological response to the compression of the fetal head during contractions and are generally considered benign.
Choice B rationale:
Pelvic pressure with contractions is a normal finding during the second stage of labor as the baby descends into the pelvis. It does not typically require reporting to the provider unless it is associated with other concerning symptoms.
Choice C rationale:
A bloody show from the vagina is a common and expected finding during the second stage of labor. It indicates that the cervix is dilating and effacing, which is a normal part of the labor process.
Choice D rationale:
A uterine contraction lasting 2 minutes is abnormal and could indicate uterine tachysystole, which can lead to fetal distress due to reduced uterine blood flow and oxygen to the fetus. This finding should be reported to the provider immediately.
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