A nurse is admitting a client who is 33 weeks pregnant and diagnosed with placenta previa.
What is the priority nursing action?

Insert an IV catheter.

Administer glucocorticoids.

Apply an external fetal monitor.

Monitor vaginal bleeding.

None

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale: Inserting an IV catheter is important for potential fluid and medication administration, but it is not the immediate priority action.

Choice B rationale: Administering glucocorticoids is important for fetal lung maturity in case of preterm birth, but it is not the immediate priority upon admission.

Choice C rationale: Applying an external fetal monitor is the priority action. It allows for continuous monitoring of the fetal heart rate and uterine activity to assess the well-being of the fetus and detect any signs of distress.

Choice D rationale: Monitoring vaginal bleeding is important for managing placenta previa, but it is not the immediate priority. Continuous fetal monitoring takes precedence to ensure fetal safety.

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Correct Answer is C

Explanation

Choice A rationale

Abdominal pain during pregnancy can be a normal part of the process as the body changes to accommodate the growing baby. However, severe abdominal pain is not normal and could be a sign of a serious condition such as preterm labor or an ectopic pregnancy.

Choice B rationale

Ballottement refers to a medical sign used in the physical examination of a pregnant woman to detect pregnancy. It involves a quick upward pushing against the uterus and feeling for return impact from the fetus. However, it is not a symptom to report during pregnancy.

Choice C rationale

A sudden gush of fluid from the vagina can be a sign of rupture of membranes, which can lead to premature birth if it occurs before 37 weeks of gestation. This is a critical symptom to report as it may indicate that labor is imminent.

Choice D rationale

Vaginal bleeding can be a sign of several serious conditions in pregnancy such as placenta previa or placental abruption. However, light spotting is common in early pregnancy.

Choice E rationale

Quickening refers to the first movement of the fetus felt by the mother, usually between 18 and 25 weeks of gestation. It is not a symptom to report during pregnancy.

A. Estrogen. B. Progesterone. C. Luteinizing Hormone (LH). D. Prostaglandins.

Correct Answer is C

Explanation

Choice A rationale

Estrogen is a hormone that plays a crucial role in the menstrual cycle and pregnancy. However, it is not the primary hormone that triggers ovulation.

Choice B rationale

Progesterone is a hormone that prepares the uterus for pregnancy after ovulation. It does not trigger ovulation.

Choice C rationale

Luteinizing Hormone (LH) is the hormone that triggers ovulation. A surge in LH levels causes the mature follicle in the ovary to burst and release an egg.

Choice D rationale

Prostaglandins are hormone-like substances involved in pain and inflammation. They do not trigger ovulation.

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A nurse is admitting a client who is 33 weeks pregnant and diagnosed with placenta previa. What is the priority nursing action?

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A nurse is admitting a client who is 33 weeks pregnant and diagnosed with placenta previa.
What is the priority nursing action?