A nurse is caring for a client who has placenta previa. Which of the following interventions should the nurse implement for this client? (Select all that apply.)
Perform a vaginal exam.
Monitor fetal heart rate with an internal fetal monitor.
Frequently assess maternal heart rate.
Initiate bed rest with bathroom privileges.
Correct Answer : C,D,E
The correct answers are C, D, E.
Choice A reason:
Performing a vaginal exam is contraindicated in placenta previa because it can disrupt the placenta and cause significant bleeding.
Choice B reason:
Monitoring fetal heart rate with an internal fetal monitor is not recommended as it involves a vaginal exam, which poses a risk of bleeding in placenta previa cases.
Choice C reason:
Frequently assessing maternal heart rate is important to detect any changes that could indicate maternal hemorrhage or other complications.
Choice D reason:
Initiating bed rest with bathroom privileges is advised to minimize the risk of bleeding and to ensure the safety of both the mother and the fetus.
Choice E reason:
Having oxygen equipment available is essential to manage potential fetal distress, which can occur with placenta previa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
High calcium levels are not typically associated with the use of anastrozole, an aromatase inhibitor. Aromatase inhibitors work by blocking the conversion of androgens to estrogens, and they do not directly impact calcium levels.
Choice B rationale:
Muscle and joint pain is a common side effect of aromatase inhibitors like anastrozole. These medications can lead to musculoskeletal discomfort, including joint stiffness and pain, which the nurse should inform the client about to ensure she is aware of potential adverse effects.
Choice C rationale:
Heart failure is not a known side effect of anastrozole. The drug's primary concern is its impact on the musculoskeletal system, particularly causing joint and muscle pain.
Choice D rationale:
Polyphagia, which refers to excessive hunger and increased food intake, is not associated with the use of anastrozole. This choice is unrelated to the side effects of the medication and can be ruled out.
Correct Answer is A
Explanation
Choice A reason:
Breastfeeding is the recommended first line of action for a newborn with a blood glucose level of 40 mg/dL, which is on the lower end of the normal range (normal range: 40-60 mg/dL for a newborn). Breast milk provides a natural source of glucose and other nutrients essential for the newborn's growth and development. It also facilitates bonding and has immunological benefits. Early initiation of breastfeeding helps to stabilize the blood glucose levels naturally.
Choice B reason:
Gavage feeding 60 mL of glucose water is not the first choice for managing borderline low blood glucose levels in a newborn. This method is typically reserved for infants who cannot feed orally due to medical conditions or prematurity. It is an invasive procedure and can be stressful for the newborn.
Choice C reason:
Administering 10 mL of D5W (5% dextrose in water) via IV is a treatment for hypoglycemia (low blood glucose levels), not for borderline low levels like 40 mg/dL. This intervention is usually considered when blood glucose levels are significantly lower than the normal range and the infant is symptomatic or unable to tolerate oral feedings.
Choice D reason:
Rechecking the glucose level in 2 hours is a passive approach and may not be appropriate for a newborn with a blood glucose level of 40 mg/dL. Immediate action, such as feeding, is preferred to prevent potential hypoglycemia and its associated risks.
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