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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Molar pregnancy is a risk factor for hyperemesis gravidarum, as it is a gestational trophoblastic disease that causes an abnormal growth of the placenta and the production of high levels of human chorionic gonadotropin (hCG), which is a hormone that stimulates nausea and vomiting. Molar pregnancy can cause severe and persistent hyperemesis gravidarum, as well as vaginal bleeding, uterine enlargement, and preeclampsia.
Choice B reason: Previous history of hyperemesis gravidarum is a risk factor for hyperemesis gravidarum, as it suggests a genetic or physiological predisposition to the condition. Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs in pregnancy, and it can cause dehydration, electrolyte imbalance, weight loss, and malnutrition. Hyperemesis gravidarum can recur in subsequent pregnancies, especially if the mother has the same partner, the same sex of the fetus, or a short interval between pregnancies.
Choice C reason: Oligohydramnios is not a risk factor for hyperemesis gravidarum, as it is a low level of amniotic fluid that surrounds the fetus. Oligohydramnios is not related to hyperemesis gravidarum, and it is not a cause or a consequence of it. Oligohydramnios can affect the fetal development and the delivery, as it can cause fetal growth restriction, cord compression, or meconium aspiration.
Choice D reason: Multiple fetal gestation is a risk factor for hyperemesis gravidarum, as it is a condition where the mother is carrying more than one fetus. Multiple fetal gestation can cause higher levels of hCG, estrogen, and progesterone, which are hormones that stimulate nausea and vomiting. Multiple fetal gestation can cause more severe and prolonged hyperemesis gravidarum, as well as preterm labor, anemia, and preeclampsia.
Correct Answer is D
Explanation
Choice A reason: Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation and pain. The risk factors for thrombophlebitis include immobility, dehydration, obesity, smoking, and cesarean birth. This client is not at increased risk for thrombophlebitis based on the information given.
Choice B reason: Retained placental fragments are pieces of the placenta that remain in the uterus after delivery and can cause bleeding, infection, or uterine subinvolution. The risk factors for retained placental fragments include placenta previa, placenta accreta, manual removal of the placenta, and incomplete separation of the placenta. This client is not at increased risk for retained placental fragments based on the information given.
Choice C reason: Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery and can cause fever, malaise, abdominal pain, and foul-smelling lochia. The risk factors for puerperal infection include prolonged rupture of membranes, prolonged labor, multiple vaginal examinations, operative delivery, and retained placental fragments. This client is not at increased risk for puerperal infection based on the information given.
Choice D reason: Uterine atony is a condition where the uterus fails to contract and retract after delivery and can cause excessive bleeding, hypovolemic shock, and hemorrhage. The risk factors for uterine atony include overdistension of the uterus, prolonged labor, oxytocin use, anesthesia, and trauma. This client is at increased risk for uterine atony due to the large size of the newborn, which can overstretch the uterus and impair its ability to contract.
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