A nurse is assisting with the admission of a client who is at 8 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?
Initiate an IV infusion of magnesium sulfate.
Administer antibiotics.
Request the RN perform a cervical examination.
Prepare for cesarean birth.
The Correct Answer is C
Choice A:
Magnesium sulfate is a medication primarily used to prevent or manage seizures in women with preeclampsia or eclampsia, conditions characterized by high blood pressure and protein in the urine during pregnancy. It is not indicated for heavy vaginal bleeding in early pregnancy.
Administration of magnesium sulfate without a clear indication could potentially lead to adverse effects such as respiratory depression, decreased deep tendon reflexes, and cardiac arrhythmias.
Choice B:
Antibiotics are used to treat bacterial infections. While heavy vaginal bleeding can sometimes be a sign of infection, it is not the primary cause of bleeding in early pregnancy.
Indiscriminate use of antibiotics without a confirmed bacterial infection can contribute to antibiotic resistance and potentially mask the underlying cause of the bleeding.
Choice D:
Cesarean birth is a major surgical procedure that is typically reserved for situations where there is a risk to the mother or fetus, such as fetal distress, failure to progress in labor, or placental abruption.
It is not indicated as the first-line intervention for heavy vaginal bleeding in early pregnancy, as there are other less invasive diagnostic and management options available.
Choice C:
A cervical examination allows the healthcare provider to assess the condition of the cervix, including its dilation and effacement, as well as to potentially identify any sources of bleeding, such as cervical polyps or lesions.
This information is crucial in determining the appropriate course of management for the patient.
It can help differentiate between potential causes of bleeding, such as threatened miscarriage, inevitable miscarriage, or ectopic pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Tachycardia, or a fast heart rate, is not a common finding in severe preeclampsia. While some women with preeclampsia may experience a slight increase in heart rate, it is not typically a significant or defining feature of the condition. In fact, some women with severe preeclampsia may even experience a slightly decreased heart rate due to increased vagal tone.
Choice B rationale:
Hypotension, or low blood pressure, is also not a typical finding in severe preeclampsia. Blood pressure is often elevated in preeclampsia, and it is one of the key diagnostic criteria. Hypotension would be a concerning finding in a woman with preeclampsia, as it could indicate a serious complication such as placental abruption or HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).
Choice C rationale:
Polyuria, or excessive urination, is not a characteristic finding of severe preeclampsia. In fact, many women with preeclampsia experience oliguria, or decreased urine output, due to decreased kidney function. This is because preeclampsia can cause damage to the blood vessels in the kidneys, impairing their ability to filter blood and produce urine.
Choice D rationale:
Headache is a common and often severe symptom of severe preeclampsia. It is thought to be caused by increased pressure within the brain due to swelling and vasoconstriction of the blood vessels. Headaches in preeclampsia can be very intense and may be accompanied by other symptoms such as blurred vision, nausea, and vomiting. They are often a sign that the preeclampsia is worsening and that delivery may be necessary.
Correct Answer is D
Explanation
Rationale for Choice A:
An IV is not routinely initiated prior to a non-stress test. It may be started if a biophysical profile (BPP), which includes an ultrasound, is also being performed, or if there is a risk of complications that may necessitate immediate intervention. However, it is not a standard part of the non-stress test itself.
Rationale for Choice B:
Nipple stimulation is not a standard component of a non-stress test. It may be used in some cases to try to induce fetal movement if the fetus is not moving actively enough during the test. However, it is not a routine part of the procedure.
Rationale for Choice C:
An ultrasound is not typically performed prior to a non-stress test. It may be done as part of a BPP, but it is not necessary for the non-stress test itself.
Rationale for Choice D:
An external fetal monitor is essential for conducting a non-stress test. This monitor uses two belts that are placed around the mother's abdomen. One belt measures the fetal heart rate, and the other belt measures uterine contractions. The monitor records the fetal heart rate and any contractions for a period of 20 to 40 minutes. The test is considered reactive (normal) if the fetal heart rate increases by at least 15 beats per minute for at least 15 seconds twice during the test. This acceleration in heart rate is typically in response to fetal movement.
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