A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4°C (97.6°F). Which of the following is the priority nursing action?

Initiate IV access.

Witness the signature for informed consent for surgery.

Insert an indwelling urinary catheter.

Prepare the abdominal and perineal areas.

Answer and Explanation

The Correct Answer is A

Choice A reason:
In the case of a client with painless, bright red vaginal bleeding at 38 weeks of gestation, the priority is to stabilize the client's condition. Initiating IV access is crucial as it allows for rapid administration of fluids or blood products to address potential hypovolemia and to prepare for the possibility of an emergency cesarean section if needed. The client's low blood pressure and elevated heart rate suggest that she may be experiencing hypovolemia, which can quickly lead to hypovolemic shock if not treated promptly.

Choice B reason:
While obtaining informed consent is important before any surgical procedure, it is not the immediate priority. The priority is to stabilize the client, and consent can be obtained concurrently with other stabilizing actions or by another member of the healthcare team.

Choice C reason:
Inserting an indwelling urinary catheter is a supportive measure that can be necessary during labor or before surgery to keep the bladder empty, reducing the risk of bladder injury during a cesarean section and monitoring urine output as an indicator of renal perfusion. However, it is not the first priority in the presence of significant vaginal bleeding.

Choice D reason:
Preparing the abdominal and perineal areas is part of the preoperative procedure for a cesarean section. This action would follow after the client has been stabilized and a decision for surgery has been made.

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Correct Answer is A

Explanation

Choice a reason:
Methylergonovine is a medication used to prevent postpartum hemorrhage, which is excessive bleeding following childbirth. It works by causing the uterine muscles to contract, thereby reducing blood loss. Postpartum hemorrhage is a significant cause of maternal morbidity and mortality worldwide, and methylergonovine is one of the medications used as a prophylactic measure to manage this risk.

Choice b reason:
While postpartum infections are a concern after childbirth, methylergonovine is not used to prevent infections. Postpartum infections can occur in different parts of the body, such as the uterus (endometritis), the urinary tract, or the site of an episiotomy or cesarean section incision. Prevention of postpartum infections typically involves hygiene practices, antibiotic prophylaxis when indicated, and monitoring for signs of infection.

Choice c reason:
Thromboembolic events, which include deep vein thrombosis and pulmonary embolism, are also a risk during the postpartum period. However, methylergonovine is not used to prevent these conditions. Prevention of thromboembolic events in the postpartum period may involve the use of anticoagulants, mechanical methods such as compression stockings, and early mobilization.

Choice d reason:
Hypertension, or high blood pressure, may be observed during the postpartum period, but methylergonovine is not indicated for the prevention of hypertension. Management of postpartum hypertension typically includes antihypertensive medications and monitoring of blood pressure levels. Methylergonovine can actually cause an increase in blood pressure as a side effect, so it must be used cautiously in individuals with hypertension.

A. A client who has a post-term pregnancy at 42 weeks of gestation. B. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation. C. A client who is experiencing fetal death at 32 weeks of gestation. D. A client who is experiencing preterm labor at 26 weeks of gestation.

Correct Answer is D

Explanation

Choice A Reason:
Tocolytic therapy is not indicated for a client with a post-term pregnancy. Tocolytics are medications used to suppress premature labor, and a pregnancy at 42 weeks is considered post-term, not preterm.

Choice B Reason:
Braxton-Hicks contractions are normal occurrences during pregnancy and do not indicate preterm labor. They are often referred to as "false labor" because they do not lead to cervical dilation or effacement. Therefore, tocolytic therapy is not necessary.

Choice C Reason:
Administering tocolytic therapy in the case of fetal death is not appropriate. Tocolytics are used to delay preterm labor to allow for fetal maturation or to prolong pregnancy to administer corticosteroids for fetal lung development, which is not applicable in this scenario.

Choice D Reason:
Tocolytic therapy is appropriate for a client experiencing preterm labor at 26 weeks of gestation. The goal of tocolytic therapy is to delay delivery to allow for the administration of corticosteroids to accelerate fetal lung maturity or to transfer the client to a facility equipped for premature infants.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer methylergonovine IM to a client who has experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

Correct Answer is A

Explanation

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

Correct Answer is D

Explanation

A nurse is preparing to administer liquid mycostatin 600,000 units PO TID. Available is mycostatin 100,000 units/mL. How many m. should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not perform an internal examination. Which of the following explanations of the primary reason should the nurse provide?

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

A nurse is caring for a client who has just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

A nurse is providing teaching to the mother of a newborn born small for gestational age (SGA). Which of the following should the nurse include as a possible cause of this condition?

A nurse is caring for a client who experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?