A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads with blood in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?
Initiation of pushing
Examination to determine cervical status
Preparation for cesarean birth
A magnesium sulfate infusion
The Correct Answer is C
Choice A reason: Initiation of pushing is not an appropriate nursing action, as it can increase the bleeding and the risk of placental separation, which can cause fetal hypoxia, hemorrhage, or shock. Pushing is contraindicated in clients with placenta previa, which is a condition where the placenta covers the cervical opening and can cause painless, bright red bleeding in the third trimester.
Choice B reason: Examination to determine cervical status is not an appropriate nursing action, as it can cause trauma and perforation of the placenta, which can lead to severe bleeding and infection. Examination is contraindicated in clients with placenta previa, unless it is confirmed by ultrasound that the placenta is not low-lying or covering the cervix.
Choice C reason: Preparation for cesarean birth is an appropriate nursing action, as it is the preferred mode of delivery for clients with placenta previa, especially if the bleeding is heavy, the fetus is mature, or the fetal distress is present. Cesarean birth can prevent the complications of placenta previa, such as fetal hypoxia, hemorrhage, or shock.
Choice D reason: A magnesium sulfate infusion is not an appropriate nursing action, as it is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, which is a hypertensive disorder of pregnancy. Magnesium sulfate is not indicated for clients with placenta previa, unless they also have severe preeclampsia or eclampsia.
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Correct Answer is A
Explanation
Choice A reason: This action is the first and most important intervention that the nurse should perform, as it can prevent or reduce the compression of the umbilical cord, which can cause fetal hypoxia, bradycardia, or death. The nurse should insert a gloved hand into the vagina and gently push the presenting part away from the cord, and maintain this position until the delivery.
Choice B reason: This action is not the first intervention that the nurse should perform, as it does not address the cause of the cord prolapse, which is the displacement of the cord below the presenting part. However, this action is helpful to prevent the drying and infection of the cord, and should be done after the first intervention.
Choice C reason: This action is not the first intervention that the nurse should perform, as it may not be effective or feasible depending on the stage of labor and the client's condition. However, this action is beneficial to reduce the pressure of the presenting part on the cord, and should be done after the first intervention.
Choice D reason: This action is not the first intervention that the nurse should perform, as it does not provide immediate relief or protection to the fetus. However, this action is necessary to expedite the delivery and prevent further complications, and should be done after the first intervention.
Correct Answer is D
Explanation
Choice A reason: Calcium carbonate is not the compound that the nurse should have readily available, as it is an antacid that neutralizes stomach acid and relieves heartburn. Calcium carbonate is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice B reason: Potassium chloride is not the compound that the nurse should have readily available, as it is an electrolyte supplement that replenishes potassium levels and prevents hypokalemia. Potassium chloride is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice C reason: Ferrous sulfate is not the compound that the nurse should have readily available, as it is an iron supplement that prevents or treats iron deficiency anemia. Ferrous sulfate is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice D reason: Calcium gluconate is the compound that the nurse should have readily available, as it is an antidote that reverses the effects of magnesium sulfate and restores calcium levels and neuromuscular function. Calcium gluconate is used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
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