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 ["B","C"]
Explanation
Choice A rationale:
The nurse does not need to report the blood pressure finding. While blood pressure is an essential vital sign to monitor during pregnancy, the scenario does not indicate any abnormalities or concerning values in the client's blood pressure. Therefore, there is no immediate cause for reporting this finding.
Choice B rationale:
The nurse should report cerebral manifestations to the provider. The client's complaint of a more severe headache, rated at 5 on a 0 to 10 pain scale, along with feeling dizzy when getting up from the examination table, may indicate potential neurological symptoms. These could be signs of conditions like preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, including the brain.
Choice C rationale:
The nurse should also report fetal heart rate findings to the provider. The client reports occasional contractions and positive fetal movement, but there is no mention of fetal heart rate in the nurse's notes. Monitoring the fetal heart rate is crucial during prenatal care, as changes in fetal heart rate could indicate fetal distress or other complications.
Choice D rationale:
The nurse does not need to report respiratory rate findings. There is no indication in the nurse's notes of any respiratory issues or complaints from the client, making this finding less relevant to the current situation.
Choice E rationale:
The nurse does not need to report deep tendon reflexes in this context. Deep tendon reflexes are not typically a priority assessment during routine prenatal care unless there are specific concerns or indications of neurological issues.
Choice F rationale:
The nurse does not need to report gastrointestinal assessment findings based on the information provided in the scenario. While the client reports "heartburn,”. there are no other gastrointestinal symptoms or indications of acute gastrointestinal issues requiring immediate reporting.
Correct Answer is A
Explanation
Choice A rationale :
The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.
Choice B rationale
Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.
Choice C rationale
Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.
Choice D rationale
Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.
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