“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
Storing a diaphragm in sterile water after each use is not necessary. After use, the diaphragm should be washed with mild soap and warm water, then air-dried.
Choice B rationale
Using an oil-based vaginal lubricant when inserting a diaphragm is not recommended. Oil- based lubricants can damage the material of the diaphragm, reducing its effectiveness.
Choice C rationale
Keeping the diaphragm in place for at least 4 hours after intercourse is correct, but it does not address the client’s postpartum status.
Choice D rationale
The client should have her provider refit her for a new diaphragm. After childbirth, a woman’s body undergoes changes that may affect the fit of her diaphragm. It is recommended that a woman be refitted for a diaphragm around 6 weeks postpartum, when the uterus and cervix have returned to normal size.
Correct Answer is B
Explanation
Choice A rationale
Limiting the length of breastfeeding to 5 minutes per breast is not typically recommended. It’s important for the baby to empty each breast completely, as the fat content of the milk increases as the breast empties.
Choice B rationale
Assessing the newborn’s latch while breastfeeding is crucial. A poor latch can cause sore nipples. The baby should take as much of the areola into their mouth as possible, with more areola showing at the top lip than the bottom.
Choice C rationale
Waiting 4 hours between daytime feedings is not typically recommended for a breastfeeding newborn. Newborns typically need to feed every 2-3 hours, or 8-12 times in 24 hours.
Choice D rationale
Offering supplemental formula between the newborn’s feedings can interfere with establishing a good milk supply and should be avoided unless medically necessary.
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