A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?
Contact social services for a temporary shelter.
Obtain a hemoglobin and hematocrit level.
Have the client transported to the hospital.
Schedule weekly perinatal appointments.
The Correct Answer is C
A. Contact social services for a temporary shelter. While contacting social services is important for the overall care of a homeless pregnant woman, it is not the immediate priority in the presence of placenta previa and vaginal bleeding.
B. Obtain a hemoglobin and hematocrit level. Assessing hemoglobin and hematocrit levels is important to evaluate the extent of blood loss and anemia, but the priority is to ensure the woman’s and fetus’s immediate safety due to placenta previa.
C. Have the client transported to the hospital. This is the correct action. Placenta previa can cause significant bleeding and requires immediate medical attention, including potential delivery. Transporting the client to the hospital ensures she receives the necessary urgent care.
D. Schedule weekly perinatal appointments. Weekly perinatal appointments are important for ongoing care, but in the context of active bleeding and placenta previa, immediate hospital care is necessary first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decreased BP during orthostatic blood pressure measurement: Syncope (fainting) often results from decreased blood flow to the brain. Orthostatic hypotension (a drop in blood pressure upon standing) can lead to syncope.
B. Grade 3 systolic murmur auscultated at the pulmonic site: A systolic murmur may indicate valvular or cardiac issues but is not directly related to syncope.
C. 3+ carotid pulse volume bilaterally: Carotid pulse volume assessment helps evaluate blood flow to the brain. Normal carotid pulses are important for preventing syncope
D. Positive jugular vein distention (JVD) bilaterally: JVD is associated with heart failure or fluid overload. While it may not directly cause syncope, it can contribute to overall cardiovascular instability.
Correct Answer is B
Explanation
A. Telling the client the medication needs more time: While true for some medications, it's important to assess the severity of the pain to determine if further action is needed.
B. Reassessing the client's pain: This is the most crucial step. Reassessment helps determine the effectiveness of the medication and identify any potential issues.
C. Asking UAP to offer a backrub: While comfort measures can be helpful, delegation to an UAP should only occur after a nurse assessment and with clear instructions. In this case, pain management is the priority.
D. Encouraging deep breaths: Distraction techniques can be a complementary approach, but reassessing the pain level is the most urgent step.
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