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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.
B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.
C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.
D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.
Correct Answer is C
Explanation
A. Notifying the facility operator is important, but it is not the immediate priority when there is a fire endangering the client's safety.
B. While closing fire doors can help contain the fire, it is not the priority action after ensuring the client's immediate safety.
C. Turning off oxygen sources is crucial because oxygen can fuel the fire and cause it to spread rapidly. This action helps prevent the fire from worsening.
D. Putting out the fire with the appropriate extinguisher is important, but it comes after ensuring the fire's fuel source is cut off to prevent further escalation of the fire.
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