A nurse is caring for a client who has a placenta previa.
Which of the following findings should the nurse expect?
Spotting.
Nausea.
Board-like abdomen.
Delayed menses.
The Correct Answer is A
Choice A rationale:
Spotting is a common finding in placenta previa. It occurs due to the abnormal implantation of the placenta over or near the cervical os, leading to vaginal bleeding. This bleeding can range from mild spotting to severe hemorrhage and is a significant sign of placenta previa.
Choice B rationale:
Nausea is not a specific sign of placenta previa. Nausea and vomiting are common symptoms during early pregnancy but are not directly related to placenta previa.
Choice C rationale:
A board-like abdomen is a sign of peritonitis or an acute abdomen, which is not associated with placenta previa. This finding suggests intra-abdominal inflammation and is unrelated to the condition in question.
Choice D rationale:
Delayed menses is a common sign of pregnancy, but it does not specifically indicate placenta previa. Placenta previa is characterized by vaginal bleeding, which is not synonymous with a delay in menstrual periods.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Recording the client's progress in the nurses' notes is important for documentation but does not directly promote communication among staff caring for the client. It is essential for the continuity of care and legal documentation, but it does not facilitate active communication between team members.
Choice B rationale:
Posting swallowing precautions at the head of the client's bed is essential for the client's safety, especially considering the risk of aspiration following a stroke. While it ensures the staff is aware of the precautions, it does not directly promote communication among the staff members.
Choice C rationale:
Having interdisciplinary team meetings for the client on a regular basis is the best choice as it promotes communication among the staff caring for the client. Interdisciplinary team meetings allow healthcare professionals from various disciplines, such as nurses, therapists, and doctors, to collaborate, share information, and discuss the best approach to care for the client. This approach ensures comprehensive and coordinated care, addressing both the client's medical and communication needs.
Choice D rationale:
Noting changes in the treatment plan in the client's medical record is crucial for documentation and continuity of care but does not actively promote real-time communication among the staff members. While it is essential for keeping the medical record updated, it does not facilitate immediate communication and collaboration between healthcare professionals.
Correct Answer is B
Explanation
Answer is: b. Document the client's condition every 15 min.
Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.
Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.
Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.
Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.
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