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 B

Explanation

Choice A reason:
Monitoring weight gain during pregnancy is important to ensure that the mother and baby are healthy. The expected weight gain during pregnancy varies depending on the mother's pre-pregnancy weight, but generally, a total gain of 25 to 35 pounds is considered normal for women of average weight.

Choice B reason:
While some nonprescription medications are safe during pregnancy, not all are, and it is crucial to consult with a healthcare provider before taking any medication, including over-the-counter ones. Certain medications can cause harm to the developing fetus and may lead to complications such as birth defects or other adverse outcomes.

Choice C reason:
Reducing stress is beneficial during pregnancy as high levels of stress can negatively impact both the mother and the developing fetus. Stress can lead to increased risks of preterm birth and low birth weight, and it can affect the baby's development. Therefore, implementing stress-reduction techniques is a positive step for a pregnant woman.

Choice D reason:
Informing the doctor before using home remedies for nausea is advisable. While many home remedies are safe and can be effective, such as ginger and peppermint, it is always best to discuss them with a healthcare provider to ensure they are appropriate and will not interfere with the pregnancy.

A. There is an increased risk of introducing infection. B. This could initiate preterm labor. C. This could result in profound bleeding. D. There is an increased risk of rupture of the membranes.

Correct Answer is C

Explanation

Choice a reason:

While there is always a risk of introducing infection with an internal examination, this is not the primary concern with placenta previa. Infections are a risk with any invasive procedure, but the precautions taken during a typical internal examination minimize this risk.

Choice b reason:

Initiating preterm labor is a concern with any manipulation of the cervix or uterus during pregnancy. However, at 37 weeks, the pregnancy is considered early-term, and the risk of preterm labor is not the primary concern in the context of placenta previa.

Choice c reason:

The primary reason for avoiding an internal examination in a client with placenta previa is the risk of profound bleeding. With placenta previa, the placenta covers part or all of the cervix. An internal examination could disturb the placenta and lead to significant hemorrhage, which can be life-threatening for both the mother and the fetus.

Choice d reason:

While there is a risk of rupturing the membranes during an internal examination, this is not the primary concern with placenta previa. The main issue is the potential for causing significant bleeding due to the placenta's location over the cervix.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

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 caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which of the following actions should the nurse take first?

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

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 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.)