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 D
Explanation
Choice A reason:
Requesting a prescription for PRN aspirin is incorrect because aspirin is an antiplatelet agent and should not be combined with heparin without specific medical advice due to the increased risk of bleeding.
Choice B reason:
Massaging the injection site is not recommended as it can cause trauma to the tissue and increase the risk of bleeding, which is especially concerning in a patient with deep-vein thrombosis.
Choice C reason:
Instructing the client that they cannot breastfeed while receiving heparin is incorrect. Heparin does not pass into breast milk in significant amounts and is considered safe for use while breastfeeding.
Choice D reason:
Administer the injection in the client's abdomen. Heparin is typically administered subcutaneously in the abdomen to ensure proper absorption and minimize discomfort. Because it is an area with large amounts of subcutaneous fat
Correct Answer is B
Explanation
A. Peanut butter and wheat bread contain high levels of phenylalanine, which should be avoided in clients with phenylketonuria.
B. A sliced apple and red grapes are low in phenylalanine and are safe choices for a client with phenylketonuria.
C. Chocolate, cookies, and milk contain phenylalanine, making them unsuitable for the client.
D. Eggs and cheese are high in phenylalanine and should be restricted in the diet.
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