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 A
Explanation
Choice A rationale:
The nurse should discontinue the oxytocin infusion if the client's contraction frequency is every 3 minutes. Frequent contractions may lead to uterine hyperstimulation, which can reduce fetal blood flow and oxygenation, potentially causing fetal distress. Normal contraction frequency during labor is typically every 2 to 5 minutes.
Choice B rationale:
Contraction duration of 100 seconds is not an indication to discontinue the oxytocin infusion. The duration of contractions can vary during labor, and 100 seconds is within the normal range of contraction duration, which is usually 45 to 90 seconds.
Choice C rationale:
Fetal heart rate with moderate variability is not an indication to discontinue the oxytocin infusion. Moderate variability in fetal heart rate is a reassuring sign, indicating a healthy fetal response to labor. It shows that the fetus is tolerating the contractions well and is not experiencing fetal distress.
Choice D rationale:
A fetal heart rate of 118/min is not an indication to discontinue the oxytocin infusion. The normal fetal heart rate range is typically between 110 to 160 beats per minute, and a heart rate of 118/min falls within this normal range. However, if the fetal heart rate deviates significantly from the normal range or shows signs of distress, further assessment and intervention are required.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should report a blood urea nitrogen (BUN) level of 35 mg/dL to the provider. BUN measures the amount of nitrogen in the blood and is used to assess kidney function. An elevated BUN can indicate impaired renal function, which is a concern in preeclampsia, as it may signify reduced blood flow to the kidneys.
Choice B rationale:
Hemoglobin (Hgb) level of 15 mg/dL is within the normal range for pregnancy (normal range: 11-15 g/dL), so there is no need to report it to the provider.
Choice C rationale:
Bilirubin level of 0.6 mg/dL is within the normal range (normal range: 0.2-1.3 mg/dL), so there is no need to report it to the provider.
Choice D rationale:
Hematocrit (Hct) level of 37% is within the normal range for pregnancy (normal range: 33- 45%), so there is no need to report it to the provider.
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