A nurse is caring for a client who is at 37 weeks of gestation and has 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.”
"There is an increased risk of introducing infection.”
"This could initiate preterm labor.”
"There is an increased risk of rupture of the amniotic membranes.”.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.
Choice B rationale:
While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.
Choice C rationale:
An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.
Choice D rationale:
While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","F"]
Explanation
The correct answers are choices B, E, and F.
Choice A rationale:
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
Choice B rationale:
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
Choice C rationale:
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
Choice D rationale:
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
Choice E rationale:
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
Choice F rationale:
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
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