Which of the following is the priority nursing action for a client at 33 weeks of gestation with a diagnosis of placenta previa?

Insert an IV catheter.

Monitor vaginal bleeding.

Apply an external fetal monitor.

Administer glucocorticoids.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Inserting an IV catheter is a standard procedure in many hospital admissions and can be necessary for administering medications and fluids. However, it is not the immediate priority in the case of placenta previa. Placenta previa is a condition where the placenta covers the cervix, and the main risk associated with it is bleeding.

Choice B reason:
Monitoring vaginal bleeding is the priority nursing action for a client with placenta previa. This condition can lead to significant bleeding, which can be life-threatening for both the mother and the fetus. The nurse must assess the amount, color, and duration of any bleeding to make timely decisions regarding the need for further medical intervention or potential delivery if the bleeding is severe.

Choice C reason:
Applying an external fetal monitor is important to assess the fetus's well-being, especially if there is vaginal bleeding or other complications. However, it is not the first action to take. The immediate concern with placenta previa is the risk of hemorrhage, which can compromise the oxygen supply to the fetus, making monitoring maternal bleeding a higher priority.

Choice D reason:
Administering glucocorticoids may be indicated to accelerate fetal lung maturity if preterm delivery is anticipated. While this is an important consideration in the management of placenta previa, especially if there is a risk of preterm birth, it is not the first line of action. The initial focus should be on assessing and controlling any bleeding to stabilize the mother's condition.

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Correct Answer is C

Explanation

Choice A reason:
Introducing fluoride supplements to a newborn is not typically recommended until the age of 6 months, unless advised by a healthcare provider due to specific water supply conditions. The American Academy of Pediatrics (AAP) suggests that fluoride supplementation should begin at 6 months if the water supply is deficient in fluoride.

Choice B reason:
Cow's milk is not recommended for infants under the age of 1 year. Introducing cow's milk before this age can lead to iron deficiency and potentially cause harm to the infant's developing kidneys. It also lacks the proper nutrients that infants require, which are found in breast milk or formula.

Choice C reason:
The AAP recommends that fruit juice should not be introduced to infants before 6 months of age. Before this age, babies should only be fed breast milk or formula. Introducing fruit juice too early can contribute to excessive weight gain and tooth decay.

Choice D reason:
The introduction of solid foods is recommended to start at around 6 months of age. Starting solid foods at 3 months is too early and can increase the risk of choking and may lead to the development of food allergies.

A. Blood pressure 148/98 mm Hg B. 3+ protein in the urine C. 1+ pitting sacral edema D. Deep tendon reflexes of +1

Correct Answer is D

Explanation

Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.

Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.

Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.

Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.

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Which of the following is the priority nursing action for a client at 33 weeks of gestation with a diagnosis of placenta previa?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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