“A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa. Which of the following assessment findings requires immediate follow-up?”
“Vaginal bleeding.”.
“Fetal heart rate of 174 bpm.”.
“Fundal height of 33 cm.”.
“Abdomen soft on palpation and without tenderness.”.
The Correct Answer is A
Choice A rationale
Placenta previa is a condition where the placenta partially or completely covers the cervix. Vaginal bleeding, often without pain, is a key symptom and requires immediate medical attention.
Choice B rationale
While a fetal heart rate of 174 bpm is slightly above the normal range (110-160 bpm), it is not the most critical finding in a patient with complete placenta previa.
Choice C rationale
A fundal height of 33 cm at 32 weeks of gestation is within the expected range and does not require immediate follow-up.
Choice D rationale
An abdomen that is soft and non-tender is a normal finding and does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying triple antibiotic ointment on the baby’s umbilical cord is not typically recommended. The American Academy of Pediatrics advises against applying any antiseptic or antibiotic ointment to the umbilical cord stump in most cases.
Choice B rationale
Giving a newborn an immersion bath daily is not recommended. Newborns do not need daily baths, and excessive bathing can dry out their skin.
Choice C rationale
Swaddling a baby with their legs in an extended position is not recommended. This position can increase the risk of developmental dysplasia of the hip.
Choice D rationale
Offering a pacifier during naps or at bedtime can be part of a safe sleep routine for a newborn, once breastfeeding is well established.
Correct Answer is B
Explanation
Choice A rationale
Taking a multivitamin daily is generally recommended during pregnancy to ensure the mother and baby receive necessary nutrients. It does not indicate a need for referral to a dietitian.
Choice B rationale
A weight gain of 4.5 kg (10 lb) since a positive pregnancy test could be a concern depending on the timeframe. If this weight gain occurred rapidly, it could indicate issues such as fluid retention or inadequate nutrition, which would warrant a referral to a dietitian.
Choice C rationale
Nausea, particularly in the morning, is a common symptom of early pregnancy often referred to as “morning sickness”. It does not typically require dietary intervention unless it is severe (hyperemesis gravidarum), leading to weight loss and dehydration.
Choice D rationale
Eating prunes is a natural method to manage constipation, a common issue during pregnancy due to hormonal changes that slow digestion. This choice does not indicate a need for a dietitian referral.
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