A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and has heavy, red vaginal bleeding without contractions, that started spontaneously. She is in no distress and states that she can "feel the baby moving.”. The client should undergo an ultrasound to determine which of the following findings?
Rh incompatibility.
Frequency and duration of contractions.
Fetal lung maturity.
Location of the placenta.
The Correct Answer is D
Choice A rationale:
Rh incompatibility is not relevant in this scenario. Rh incompatibility refers to a condition where the mother's blood is Rh-negative, and the baby's blood is Rh-positive, which can lead to hemolytic disease of the newborn. However, this condition is unrelated to the client's current presentation of heavy, red vaginal bleeding without contractions.
Choice B rationale:
Frequency and duration of contractions are not the primary concern in this situation. The client's main complaint is heavy vaginal bleeding without contractions, which indicates a potential issue with the placenta or other pregnancy-related problems.
Choice C rationale:
Fetal lung maturity is not the priority at this stage. The client is at 38 weeks of gestation, which is considered full term. Fetal lung maturity is typically assessed if there's a need for early delivery, which is not indicated in this scenario.
Choice D rationale:
The correct choice. The client is experiencing heavy, red vaginal bleeding, which may be a sign of placental abruption, where the placenta separates from the uterine wall prematurely. Determining the location of the placenta through an ultrasound can help identify if placental abruption is the cause of bleeding. Placental abruption can be a serious condition that requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Dry the newborn.
Choice A rationale:
Confirming identification and applying a bracelet is important for ensuring the newborn’s identity and preventing mix-ups, but it is not the immediate priority right after birth.
Choice B rationale:
Examining the newborn for birth defects is crucial for identifying any immediate health concerns, but it should be done after initial stabilization measures like drying and warming the newborn.
Choice C rationale:
Drying the newborn is the first action the nurse should take immediately after delivery. This helps to prevent heat loss and maintain the newborn’s body temperature, which is critical for their survival and well-being.
Choice D rationale:
Conducting a gestational age assessment is important for determining the newborn’s maturity and potential health risks, but it is not the immediate priority right after birth.
Correct Answer is D
Explanation
Choice A rationale :
Contractions every 3 to 4 minutes. Rationale: Contractions are a significant sign of labor. When the uterus contracts regularly and with increasing intensity, it indicates that the woman is in labor. However, contractions alone may not be enough to confirm active labor, as Braxton Hicks contractions can occur earlier in pregnancy, which are often irregular and less intense.
Choice B rationale
Pain just above the navel. Rationale: Pain above the navel is not a specific indicator of labor. In late pregnancy, the baby's head may engage in the pelvis, causing pressure and discomfort in the upper abdomen. However, this symptom alone does not confirm active labor and can be attributed to various other factors as well.
Choice C rationale
Amniotic fluid in the vaginal vault. Rationale: The presence of amniotic fluid in the vaginal vault, also known as rupture of membranes or "water breaking,”. is a significant sign that labor is likely to be in progress or imminent. When the amniotic sac ruptures, it releases the fluid that surrounds the baby in the uterus. This is a clear indication of active labor.
Choice D rationale
Cervical dilation. Rationale: Cervical dilation is one of the most reliable signs of active labor. As the uterus contracts, the cervix starts to dilate and efface (thin out) to allow the baby's passage through the birth canal. Measuring cervical dilation during a pelvic examination provides valuable information about the progress of labor.
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