A nurse is assisting with the care of a client who is at 28 weeks of gestation.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Potential Condition: Placenta previa
- This condition is characterized by the placenta covering the cervix, which can lead to painless, bright red vaginal bleeding during the second or third trimester.
- Actions to Take:
1. Insert a large-bore peripheral IV catheter.
- This is a precautionary measure to ensure that there is immediate venous access for fluid and blood product administration if necessary.
2. Reinforce with the client to maintain bed rest.
- Limiting physical activity can help reduce the risk of further bleeding.
- Parameters to Monitor:
1. Vaginal bleeding
- Monitoring the amount, color, and frequency of bleeding is crucial to assess the ongoing blood loss and stability of the condition.
2. Fetal well-being
- Regular monitoring of fetal heart rate and movement is important to ensure the fetus is not in distress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Blurred vision can indicate a prenatal complication, such as preeclampsia, which is a serious condition that can develop in the later stages of pregnancy and requires immediate attention. Preeclampsia can lead to severe health issues for both the mother and baby.
B. Shortness of breath can be a normal part of late pregnancy due to the pressure on the diaphragm from the growing uterus. While it should be monitored, it is not specifically indicative of a complication compared to other symptoms.
C. Non-pitting ankle edema is common in the later stages of pregnancy and is not necessarily a sign of a complication on its own. It can occur due to the increased fluid volume and pressure from the uterus.
D. Leukorrhea, or increased vaginal discharge, is a common and normal finding in pregnancy, especially as labor approaches. It is generally not a sign of a complication unless accompanied by other concerning symptoms.
Correct Answer is A
Explanation
A. Chronic hypertension is a significant risk factor for preeclampsia. Pregnant clients with pre-existing high blood pressure are at increased risk for developing this condition, which can lead to complications for both the mother and the baby.
B. Maternal age of 30 years is not considered a high-risk factor for preeclampsia. Advanced maternal age (35 years and older) is more commonly associated with an increased risk.
C. The third pregnancy alone is not a risk factor for preeclampsia. First pregnancies or a history of preeclampsia in previous pregnancies are more relevant risk factors.
D. A prepregnancy BMI of 19 is within the normal weight range and is not associated with an increased risk of preeclampsia. Obesity or a high BMI is more closely linked to the development of preeclampsia.
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