A nurse is caring for a client who is at 37 weeks of gestation and diagnosed with placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
"This could result in profound bleeding."
"This could initiate preterm labor."
"There is an increased risk of rupture of the membranes."
"There is an increased risk of introducing infection."
The Correct Answer is A
Explanation:
A. "This could result in profound bleeding."
This is the correct explanation. Placenta previa involves the placenta partially or completely covering the cervix. Performing an internal examination, such as a vaginal exam, can disrupt the placenta and lead to severe bleeding. This bleeding can be dangerous for both the mother and the baby, making it a critical concern to avoid internal exams in placenta previa cases.
B. "This could initiate preterm labor."
While internal examinations may trigger preterm labor in some cases, the primary concern in placenta previa is the risk of significant bleeding. Preterm labor is not typically the primary reason for avoiding internal exams in placenta previa; instead, the focus is on preventing bleeding and its associated complications.
C. "There is an increased risk of rupture of the membranes."
While an internal examination may carry a risk of membrane rupture, especially in situations with low-lying placenta or marginal previa, the primary concern in placenta previa is the potential for severe bleeding if the placenta is disturbed. Rupture of membranes is a consideration but is not the main reason for avoiding internal exams in placenta previa.
D. "There is an increased risk of introducing infection."
While infection is a concern with any invasive procedure, including internal examinations, it is not typically the primary reason for avoiding internal exams in placenta previa. The main focus is on preventing bleeding complications that can arise from disrupting the placenta.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
A. Excessive uterine enlargement
This choice is correct because a hydatidiform mole can cause rapid and excessive growth of the uterus due to the abnormal proliferation of placental tissue. This can lead to the uterus being larger than expected for the gestational age.
B. Profuse, clear vaginal discharge
This choice is not typically associated with a hydatidiform mole. While vaginal discharge can occur during pregnancy, a profuse and clear discharge is not specifically characteristic of a hydatidiform mole. Other causes, such as normal vaginal secretions or infections, could lead to such discharge.
C. Rapid decline in human chorionic gonadotropin (hCG) levels
This choice is not typical of a hydatidiform mole. In fact, one of the hallmarks of a molar pregnancy is an abnormally high level of hCG. The hCG levels may continue to rise instead of declining rapidly.
D. Irregular fetal heart rate
This choice is not associated with a hydatidiform mole because a molar pregnancy does not involve a viable fetus with a heartbeat. Instead, it is characterized by the abnormal growth of placental tissue, which can cause symptoms related to uterine enlargement and complications such as bleeding or preeclampsia, but not an irregular fetal heart rate.
Correct Answer is B
Explanation
Explanation:
To calculate the estimated date of delivery (EDD) based on the client's last menstrual period (LMP), the nurse can use Naegele's rule. Naegele's rule calculates the EDD by adding 7 days to the first day of the LMP, subtracting 3 months, and then adding 1 year.
Given the client's last menstrual period was July 4, 2020, we can apply Naegele's rule:
Add 7 days to July 4, 2020: July 11, 2020
Subtract 3 months: April 11, 2020
Add 1 year: April 11, 2021
Therefore, the appropriate response by the nurse is:
B. April 11, 2021
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