A nurse is assisting in the care of a 34-year-old female client in the antepartum unit. The client is 28 weeks pregnant and has a history of vaginal bleeding. She presents with active bleeding and fetal heart rate abnormalities.

Exhibits

Complete the diagram by dragging from the choices below to specify:

Answer and Explanation

The Correct Answer is []

Condition: Placenta previa

2 actions:

Reinforce bed rest and maintain IV access
Prepare for an emergency cesarean birth

2 parameters:

Fetal heart rate
Maternal oxygen saturation

Rationale for correct condition: Placenta previa is indicated by painless, bright red vaginal bleeding in the third trimester, without abdominal pain or uterine tenderness. The fetal heart rate shows abnormalities with minimal variability, which can occur due to placental issues. Fundal height consistent with gestational age and absence of contractions support this diagnosis. Diagnosing this early is crucial as it poses significant risks to both the mother and fetus. The client’s history of bleeding and current symptoms align with placenta previa more than other conditions.

Rationale for actions: Reinforcing bed rest helps minimize bleeding and maintains stability. IV access is crucial for fluid management and potential blood transfusion. Preparing for an emergency cesarean birth ensures prompt delivery if maternal or fetal status deteriorates, preventing severe complications. Administering broad-spectrum antibiotics isn’t directly indicated as there's no sign of infection. Methotrexate is inappropriate here as it treats ectopic pregnancies, not placental issues. Encouraging ambulation might exacerbate bleeding, worsening the condition.

Rationale for parameters: Monitoring fetal heart rate assesses fetal well-being and detects distress early. Maternal oxygen saturation is vital to ensure adequate oxygen delivery to both mother and fetus. WBC count isn't immediately relevant unless there's an infection concern. Urine output doesn’t directly indicate placental health. Uterine contractions are irrelevant since there are no signs of preterm labor or irritability.

Rationale for incorrect conditions: Abruptio placentae usually involves painful bleeding with uterine tenderness or contractions. Preterm labor is characterized by regular contractions leading to cervical changes, absent here. Uterine rupture often involves severe pain, sudden fetal distress, and maternal shock, none of which are present.

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Correct Answer is A

Explanation

Choice A rationale

Repositioning the newborn every 2 hours during phototherapy is important to ensure even exposure to the light and to prevent skin breakdown. This practice helps in the effective reduction of bilirubin levels.

Choice B rationale

Giving the newborn 30 ml of distilled water after each feeding is not recommended. Hydration is typically maintained through breastfeeding or formula feeding, and additional water is not necessary.

Choice C rationale

Monitoring the newborn's blood glucose level every hour is excessive and not standard practice for phototherapy management. Routine blood glucose monitoring is not indicated unless there are specific concerns.

Choice D rationale

Applying a water-based ointment to the newborn's skin every 6 hours is not necessary and could interfere with the effectiveness of phototherapy. The skin should be kept clean and dry for optimal light exposure. .

A. We will scan your baby's identification bracelet each shift. B. You should check the identity of individuals who come to remove your baby from the room. C. We will match the bracelet on your baby with his footprints each shift. D. Your baby will wear an electronic bracelet when he is out of your room.

Correct Answer is B

Explanation

Choice A rationale

While scanning the baby's identification bracelet each shift can ensure correct identification, it does not directly involve the parents in the safety and identification process. Active involvement of parents in verifying individuals who come to remove the baby from the room enhances security and reduces the risk of accidental or unauthorized removal of the baby.

Choice B rationale

Parents should check the identity of individuals who come to remove their baby from the room to ensure safety and proper identification. This practice ensures that the parents are directly involved in their baby's security, reducing the chances of misidentification or unauthorized removal.

Choice C rationale

Matching the bracelet on the baby with his footprints each shift is not a standard procedure for newborn identification and safety. Footprints are typically used at birth for identification purposes, but continuous matching with the bracelet is not practical or commonly practiced.

Choice D rationale

While an electronic bracelet can enhance newborn safety by tracking their location, it does not replace the importance of parental vigilance. Ensuring the parents check the identity of anyone who comes to remove the baby provides an additional layer of security that complements the electronic bracelet system.

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following interventions should the nurse recommend including in the plan?

Correct Answer is A

Explanation

A nurse is reviewing the facility protocol about newborn identification and safety with a new parent. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse is reinforcing discharge teaching about home safety with a client who is postpartum. In which of the following positions should the nurse instruct the client to place their newborn in the crib?

A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy. Which of the following discomforts should the nurse include in the teaching?

A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride. Which of the following manifestations should the nurse identify as an adverse effect of this medication?

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