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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as it is not helpful to use euphemisms or avoid the words dead or died when talking about the loss of an infant. Using the words lost or gone can imply that the baby is not really dead, or that the baby can be found or returned, which can create confusion and denial in the family. Using the words dead or died can help the family to acknowledge and accept the reality of the loss, and to express their grief and emotions.
Choice B reason: This statement is incorrect, as it is not helpful to set a firm time for ending the visit with the baby, as it can make the parents feel rushed, pressured, or controlled. Setting a firm time for ending the visit can interfere with the parents' natural process of saying goodbye to the baby, and can prevent them from creating memories and bonding with the baby. The parents should be allowed to decide how long they want to spend with the baby, and to end the visit when they are ready.
Choice C reason: This statement is incorrect, as it is not helpful to encourage the family not to give the baby a name, as it can make the baby seem less real, less important, or less valued. Encouraging the family not to give the baby a name can deny the family's right to recognize and honor the baby as a person, and to establish a relationship and an identity with the baby. The family should be supported to give the baby a name, and to use the name when referring to the baby.
Choice D reason: This statement is correct, as it is helpful to ensure the baby is clothed or wrapped if the parents choose to visit with the baby, as it can make the baby look more comfortable, warm, and human. Ensuring the baby is clothed or wrapped can facilitate the parents' physical contact and interaction with the baby, and can enhance the parents' perception and memory of the baby. The parents should be offered to choose the clothing or the blanket for the baby, and to keep them as mementos.
Correct Answer is C
Explanation
Choice A reason: Nervousness is a common and expected side effect of terbutaline, which is a beta-2 adrenergic agonist that stimulates the sympathetic nervous system and relaxes the uterine smooth muscle. The nurse does not need to report this finding to the provider, but can provide reassurance and comfort to the client.
Choice B reason: Tremors are also a common and expected side effect of terbutaline, as it causes increased muscle activity and shakiness. The nurse does not need to report this finding to the provider, but can monitor the client's vital signs and electrolyte levels, and advise the client to avoid caffeine and other stimulants.
Choice C reason: Dyspnea is an uncommon and serious side effect of terbutaline, as it can indicate pulmonary edema, which is a life-threatening condition where fluid accumulates in the lungs and impairs gas exchange. The nurse should report this finding to the provider immediately and prepare for interventions, such as oxygen therapy, diuretics, or discontinuation of terbutaline.
Choice D reason: Headaches are also a common and expected side effect of terbutaline, as it causes vasodilation and increased blood flow to the brain. The nurse does not need to report this finding to the provider, but can administer analgesics as prescribed, and encourage the client to rest and hydrate.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.