A client who has a diagnosis of complete placenta previa is admitted to the labor and
delivery suite at 36 weeks gestation with contractions 5 minutes in frequency and 1 minute in duration. Which of the following actions should the nurse take?
Rupture the amniotic sac.
Medicate the client for pain.
Prepare the client for a cesarean section.
Perform a vaginal exam.
The Correct Answer is C
A. Rupturing the amniotic sac in the case of complete placenta previa can lead to significant bleeding and is contraindicated.
B. Pain medication may be administered if needed, but the priority is to address the placenta previa and potential complications.
C. Complete placenta previa at 36 weeks gestation with contractions and bleeding is a clear
indication for an emergency cesarean section to prevent maternal hemorrhage and fetal distress.
D. Performing a vaginal exam can increase the risk of bleeding and should be avoided in cases of placenta previa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Diabetes mellitus is not a contraindication for methylergonovine, although blood glucose should be monitored in all postpartum clients.
B. Hypertension is a contraindication because methylergonovine causes vasoconstriction, which can dangerously elevate blood pressure and increase the risk of stroke or other cardiovascular complications.
C. Migraine headaches are not an absolute contraindication, although ergot derivatives can potentially exacerbate migraines in some clients.
D. Hepatitis B is not a contraindication, though liver function should be monitored when using medications metabolized by the liver.
Correct Answer is B
Explanation
A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.
B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.
C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.
D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.
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