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 ["0504"]

Explanation

To calculate the estimated date of birth (EDB), also known as the due date, we use Naegele's Rule, which involves adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). Using this rule, if the LMP was on July 27, the EDB would be:

- Add one year: July 27, 2024
- Subtract three months: April 27, 2024
- Add seven days: May 4, 2024

Therefore, the EDB in MMDD format is 0504.
Reason:
Naegele's Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the date of a woman's last menstrual period (LMP). This calculation assumes a regular menstrual cycle of 28 days and ovulation occurring on the 14th day of the cycle. The EDB is typically set at 40 weeks from the LMP, which is approximately 280 days. While this method provides an estimate, only about 4% of births occur on the exact due date, and most births occur within a range of two weeks before or after the estimated due date.

It's important to note that the EDB is an estimate and can be influenced by factors such as the length of menstrual cycles, the exact day of ovulation, and the date of conception. Ultrasounds and other prenatal tests can provide additional information to refine the due date estimate as the pregnancy progresses.

A. "Exposure to rubella will suppress the newborn's immune response." B. "The child might develop encephalitis, a complication of rubella." C. "The newborn is at risk for developing a TORCH infection." D. "The newborn might be actively shedding the virus."

Correct Answer is D

Explanation

Choice A reason:
The statement that exposure to rubella will suppress the newborn's immune response is not entirely accurate. While rubella can affect the immune system, the primary concern with newborns is the risk of congenital rubella syndrome (CRS), which can cause a variety of health problems, including developmental delays and organ damage. The newborn's immune system is not fully developed, and while rubella can lead to immunosuppression, the main reason for isolation is to prevent the spread of the virus.

Choice B reason:
Encephalitis is an inflammation of the brain that can be caused by various infections, including rubella. However, it is not the most common complication associated with congenital rubella. The primary concerns with CRS are hearing loss, heart defects, and ocular issues, such as cataracts. While encephalitis is a serious condition, the immediate reason for isolation is to prevent the transmission of the virus, not specifically because of the risk of encephalitis.

Choice C reason:
TORCH infections refer to a group of infections that can cause serious health problems in newborns. The acronym stands for Toxoplasmosis, Other (such as syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus. While it is true that the newborn is at risk for developing CRS, which is part of the TORCH group, the term "TORCH infection" is a broader category and does not specifically explain why the newborn is being isolated.

Choice D reason:
The most appropriate response is that the newborn might be actively shedding the virus. Newborns with congenital rubella can shed the virus for an extended period after birth. This means they can potentially spread the virus to others, which is why isolation is necessary. Isolation helps protect other newborns, pregnant women, and immunocompromised individuals from contracting rubella, which can have serious consequences.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD format. For example, July 27 is 0727.)

Correct Answer is ["0504"]

Explanation

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

A nurse is caring for a client who is at 28 weeks of gestation and has:

A nurse is caring for a client who experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?

A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

A nurse is caring for a client who is postpartum and has received methylergonovine. Which of the following findings indicates that the medication was effective?

A nurse is caring for a client who is at 40 weeks of gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being the most reliable?

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?