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
None
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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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Maintain the patient on bed rest. This is a common nursing intervention for a patient who is experiencing an inevitable abortion. Bed rest can help reduce the risk of further complications, such as heavy bleeding. It can also provide the patient with a chance to rest and recover physically and emotionally.
Choice B rationale
Offer the option to view products of conception. This intervention may not be appropriate for all patients. While some patients may find it helpful to view the products of conception, others may find it distressing. It’s important to discuss this option with the patient and respect her wishes.
Choice C rationale
Administer oxygen via a nasal cannula. This intervention may not be necessary for all patients experiencing an inevitable abortion. While oxygen therapy can be used to treat hypoxia in patients with heavy bleeding, it’s not typically required unless the patient shows signs of hypoxia.
Choice D rationale
Instruct the patient to increase potassium-rich foods in the diet. This intervention is not typically part of the care plan for a patient experiencing an inevitable abortion. While a balanced diet is important for overall health, there’s no specific need to increase potassium-rich foods in the diet in this situation.
Correct Answer is A
Explanation
Choice A rationale
The nurse should include in the teaching that a client who is 23 weeks pregnant can receive an influenza vaccination during pregnancy. This is because the influenza vaccine is safe and recommended for pregnant women to protect both the mother and the baby from the flu.
Choice B rationale
The rubella vaccine is a live vaccine and is not recommended during pregnancy or while breastfeeding due to the potential risk to the baby. However, it can be given immediately after delivery if the woman is not immune.
Choice C rationale
The varicella vaccine is also a live vaccine and is not recommended during pregnancy. It should be given before pregnancy or immediately after delivery if the woman is not immune.
Choice D rationale
The Tdap (Tetanus, Diphtheria, Pertussis) vaccine is actually recommended during each pregnancy, regardless of the patient’s previous history of receiving the vaccine. The optimal timing for Tdap administration is between 27 and 36 weeks of gestation.
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