A pregnant client presents with painless bleeding caused by placenta previa at 37 weeks' gestation.
Which assessment is the most important for the nurse to perform?
Measurement of fundal height.
Digital vaginal examination for dilation.
Assessment of maternal temperature.
Monitor fetal heart rate and contraction patterns.
The Correct Answer is D
Choice A rationale
Fundal height measurement assesses fetal growth, which is important but less critical than fetal well-being in a bleeding emergency. Placenta previa involves placental implantation near or over the cervical os, causing painless bleeding. Fetal distress from hypovolemia or prematurity is the most immediate life threat. The normal fundal height range is approximately equal to the weeks of gestation ± 2 cm after 20 weeks.
Choice B rationale
A digital vaginal examination is contraindicated in a client with painless, bright red bleeding suspicious of placenta previa. This action could accidentally rupture the placenta or vessels, leading to catastrophic hemorrhage and fetal distress by potentially causing placental separation or tearing of the vasa previa if present.
Choice C rationale
Assessment of maternal temperature is part of a routine vital sign assessment, mainly to detect infection (chorioamnionitis), which can cause preterm labor or rupture of membranes, but is not the priority over assessing the immediate maternal and fetal response to the hemorrhage. Normal maternal temperature is about 36.1°C to 37.2°C (97.0°F to 99.0°F).
Choice D rationale
Continuous monitoring of the fetal heart rate (FHR) and contraction patterns is the most crucial assessment to determine fetal status and well-being. Bleeding from placenta previa can quickly compromise uteroplacental perfusion, leading to fetal hypoxia, distress (e.g., non-reassuring FHR patterns), or premature labor, necessitating immediate intervention. Normal FHR is 110-160 beats per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
Step 1 is: Calculate the volume of the magnesium sulfate solution that contains the ordered dose. 500 mL÷30 g = 16.666. mL/g. 6 g/hr×16.666. mL/g = 100 mL/hr. The final calculated answer is 100 mL/hr.
Correct Answer is D
Explanation
Choice A rationale
Placing a rolled towel under the client's knees is generally discouraged because it can promote venous stasis in the lower extremities by compressing the popliteal vein, thereby increasing the risk of developing a deep vein thrombosis (DVT). While comfort measures are important, this specific action is not a critical immediate action necessary for safety or to advance care upon admission to the labor unit.
Choice B rationale
The healthcare provider must be notified of the client's admission and status, but this is not the most critical immediate action for the nurse. The immediate priority upon admission is to complete the initial assessment, which includes establishing the fetal heart rate (FHR) baseline (which is currently being monitored) and assessing the stage of labor through a sterile vaginal exam, then notifying the provider with complete findings.
Choice C rationale
Administering supplemental oxygen via a non-rebreather mask (NRB) is indicated for signs of maternal hypoxemia (low oxygen saturation) or for fetal distress. Although the client has an increased respiratory and cardiac rate, her lungs are clear, and she is alert, suggesting anxiety or labor pain is the likely cause. Oxygen is not immediately required without evidence of true hypoxemia.
Choice D rationale
Performing a sterile vaginal exam (SVE) to assess cervical dilation and effacement is a critical, immediate action upon admission to the labor unit to determine the stage of labor. This information is essential for triage, ongoing management, and planning. It provides the baseline data needed to compare against subsequent exams and to communicate the client's status effectively to the healthcare provider.
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