A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?

Initiate continuous monitoring of the FHR.

Administer a dose of betamethasone.

Check the cervix for dilation every 8 hours.

Request that the provider prescribe misoprostol PRN.

Answer and Explanation

The Correct Answer is A

The correct answer is A. Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply

Choice A reason:

Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.

Choice B reason:

Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.

Choice C reason:

Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.

Choice D reason:

Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.

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Correct Answer is A

Explanation

The correct answer is A. Apply an ice pack to the affected area. Ice packs are recommended during the first 24 hours after birth to decrease swelling and help with pain.

Choice A reason: Applying an ice pack to the episiotomy site helps reduce swelling and provides pain relief. This is the standard care within the first 24 hours postpartum.

Choice B reason: A warm sitz bath is generally recommended after the first 24 hours following birth. It is not the best immediate action for unrelieved pain shortly after delivery.

Choice C reason: While maintaining cleanliness with a squeeze bottle of antiseptic solution is important for preventing infection, it does not provide the immediate pain relief needed for unrelieved episiotomy pain.

Choice D reason: Heat application, such as placing a hot pack, is not advised within the first 24 hours postpartum because it can increase the risk of swelling and bleeding.

A. Point out to the father that the newborn turns toward his voice. B. Ask the father why he is concerned about bonding with the newborn. C. Encourage the father to touch and stroke the newborn's skin. D. Demonstrate diapering and swaddling techniques for the father. E. Encourage the father to lay the newborn beside him while both are sleeping.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Pointing out to the father that the newborn turns toward his voice helps him understand that the baby is already responding to him, promoting bonding.

Choice B rationale:

Asking the father why he is concerned about bonding with the newborn allows the nurse to address specific fears or misconceptions and provide appropriate support.

Choice C rationale:

Encouraging the father to touch and stroke the newborn's skin promotes physical contact and enhances the bonding process.

Choice D rationale:

Demonstrating diapering and swaddling techniques for the father helps him feel more confident in caring for his baby and fosters bonding through caregiving activities.

Choice E rationale:

Encouraging the father to lay the newborn beside him while both are sleeping promotes skin- to-skin contact and allows for bonding during restful moments. However, the nurse should ensure that safety measures are followed to prevent accidental suffocation. By following these actions, the nurse can support the father's bonding with his newborn and facilitate a positive and nurturing parent-infant relationship.

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A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a newborn whose father voices concerns about his ability to bond with his baby. Which of the following actions should the nurse take to facilitate bonding? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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