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 D

Explanation

Choice A reason:
A negative rubella titer indicates that the client does not have immunity to the rubella virus. Immunity would be indicated by a positive titer, showing the presence of rubella IgG antibodies in the blood. Therefore, this choice is incorrect.

Choice B reason:
While the client does not have immunity, administering a rubella vaccination during pregnancy is not recommended due to the theoretical risk to the fetus. Vaccinations with live viruses, like the rubella vaccine, are generally avoided during pregnancy.

Choice C reason:
A negative rubella titer does indeed indicate that the client is not currently experiencing a rubella infection, as active infection would be indicated by the presence of rubella IgM antibodies. However, this choice does not address the client's susceptibility to future infection or the need for immunization.

Choice D reason:
The correct interpretation of a negative rubella titer in an antepartum client is that she is not immune to rubella and should receive the rubella immunization after delivery. This is to ensure immunity and prevent the possibility of contracting rubella in future pregnancies, which could be harmful to the fetus.

A. We can time your pain medication so that you have an hour or two before the next feeding. B. You need to take pain medications so you are more comfortable. C. All medications are found in breast milk to some extent. D. You have the option of not taking pain medication if you are concerned.

Correct Answer is A

Explanation

Choice a) reason:
Timing the administration of pain medication can help minimize the amount of medication that passes into the breast milk. By scheduling pain relief around breastfeeding times, the nurse can ensure that the peak concentration of the medication in the blood (and therefore potentially in the milk) does not coincide with the baby's feeding times. This approach helps manage the mother's pain while also protecting the newborn from unnecessary exposure to medication.

Choice b) reason:
While managing pain is important for the mother's comfort and recovery, stating that she needs to take medication without considering her concerns about breastfeeding may not be supportive or respectful of her wishes. It's essential to address her concerns and provide options that align with her breastfeeding goals.

Choice c) reason:
It is true that all medications can be found in breast milk to some extent; however, the levels can vary widely based on the medication's properties. The nurse should provide information about the specific medication's safety during breastfeeding and discuss any potential risks with the mother.

Choice d) reason:
Informing the mother that she has the option of not taking pain medication addresses her autonomy in decision-making. However, it's also important for the nurse to discuss the potential consequences of untreated pain, such as impaired ability to care for the newborn and delayed recovery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity from magnesium sulfate therapy and report to the provider?

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

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 admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

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?

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 36 weeks of gestation and has a suspected placenta previa. Which of the following findings support this diagnosis?