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?
"There is an increased risk of introducing infection.”
"This could initiate preterm labor.”
"This could result in profound bleeding.”
"There is an increased risk of rupture of the membranes.”
The Correct Answer is C
Choice A rationale:
While there is a risk of infection with any internal examination, it is not the primary reason for avoiding internal examinations in a client with placenta previa. The main concern is avoiding trauma to the placenta, which could result in significant bleeding.
Choice B rationale:
Although internal examinations may potentially stimulate uterine contractions, leading to preterm labor in some cases, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
Choice C rationale:
The correct explanation for the nurse to provide is that an internal examination could result in profound bleeding. Placenta previa occurs when the placenta partially or completely covers the cervix, and any manipulation of the cervix or uterus through an internal examination could disrupt the placenta and cause severe bleeding, endangering both the mother and the baby.
Choice D rationale:
While there is a risk of rupturing the membranes during an internal examination, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Before an amniocentesis, it is essential for the client to empty their bladder. A full bladder can interfere with the procedure, as it may obstruct the needle's entry into the uterus and increase the risk of accidental bladder puncture.
Choice B rationale:
Nothing by mouth (NPO) for 4 hours is not necessary for an amniocentesis. It is a relatively simple and quick procedure that does not require fasting.
Choice C rationale:
Ingesting 3 liters of water is not indicated before an amniocentesis. While some ultrasound examinations may require a full bladder, this is not the case for an amniocentesis.
Choice D rationale:
Nipple stimulation is not relevant or necessary before an amniocentesis. Nipple stimulation can trigger uterine contractions, which might be undesirable before the procedure, especially if the client is not in labor.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Pointing out to the father that the newborn turns toward his voice helps him understand that the baby is already responding to him, promoting bonding.
Choice B rationale:
Asking the father why he is concerned about bonding with the newborn allows the nurse to address specific fears or misconceptions and provide appropriate support.
Choice C rationale:
Encouraging the father to touch and stroke the newborn's skin promotes physical contact and enhances the bonding process.
Choice D rationale:
Demonstrating diapering and swaddling techniques for the father helps him feel more confident in caring for his baby and fosters bonding through caregiving activities.
Choice E rationale:
Encouraging the father to lay the newborn beside him while both are sleeping promotes skin- to-skin contact and allows for bonding during restful moments. However, the nurse should ensure that safety measures are followed to prevent accidental suffocation. By following these actions, the nurse can support the father's bonding with his newborn and facilitate a positive and nurturing parent-infant relationship.
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