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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While determining the viability of the fetus is an important aspect of prenatal care, it is not the primary purpose of an ultrasound in this scenario. The client’s report of feeling the baby moving suggests that the fetus is likely viable.
Choice B rationale
The primary purpose of the ultrasound in this scenario is to locate the placenta. Heavy, red vaginal bleeding at 38 weeks of gestation could indicate a complication such as placenta previa, where the placenta covers the cervix. An ultrasound can help confirm this diagnosis.
Choice C rationale
Measuring the biparietal diameter is a method used to estimate fetal weight and gestational age. However, in this scenario, the client is already known to be at 38 weeks of gestation, and the sudden onset of heavy, red vaginal bleeding is a more immediate concern.
Choice D rationale
Assessing fetal lung maturity is typically done when there is a risk of preterm delivery. In this scenario, the client is already at 38 weeks of gestation, which is considered full term. The immediate concern is the heavy, red vaginal bleeding.
Correct Answer is D
Explanation
Choice A rationale
While seeing a counselor could be beneficial for some women experiencing doubts and second thoughts about their pregnancy, it is not necessarily the first or only option. Many women experience a range of emotions during pregnancy, and these feelings are often temporary.
Choice B rationale
Telling a woman not to worry and that she will be fine once the baby is born may minimize her feelings and concerns. It’s important to validate her feelings and provide support.
Choice C rationale
While talking to a trusted family member or friend can be helpful, it’s not the only option. Some women may not feel comfortable discussing their feelings with family members.
Choice D rationale
Ambivalent feelings are quite common for women early in pregnancy. It’s a time of significant change, and it’s normal to have mixed feelings about it. It can be helpful to discuss these feelings with a healthcare provider, who can provide reassurance and resources.
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