A nurse is admitting a client who is 33 weeks pregnant and diagnosed with placenta previa.
What is the priority nursing action?
Insert an IV catheter.
Administer glucocorticoids.
Apply an external fetal monitor.
Monitor vaginal bleeding.
None
None
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale: Inserting an IV catheter is important for potential fluid and medication administration, but it is not the immediate priority action.
Choice B rationale: Administering glucocorticoids is important for fetal lung maturity in case of preterm birth, but it is not the immediate priority upon admission.
Choice C rationale: Applying an external fetal monitor is the priority action. It allows for continuous monitoring of the fetal heart rate and uterine activity to assess the well-being of the fetus and detect any signs of distress.
Choice D rationale: Monitoring vaginal bleeding is important for managing placenta previa, but it is not the immediate priority. Continuous fetal monitoring takes precedence to ensure fetal safety.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While determining the viability of the fetus is an important aspect of prenatal care, it is not the primary purpose of an ultrasound in this scenario. The client’s report of feeling the baby moving suggests that the fetus is likely viable.
Choice B rationale
The primary purpose of the ultrasound in this scenario is to locate the placenta. Heavy, red vaginal bleeding at 38 weeks of gestation could indicate a complication such as placenta previa, where the placenta covers the cervix. An ultrasound can help confirm this diagnosis.
Choice C rationale
Measuring the biparietal diameter is a method used to estimate fetal weight and gestational age. However, in this scenario, the client is already known to be at 38 weeks of gestation, and the sudden onset of heavy, red vaginal bleeding is a more immediate concern.
Choice D rationale
Assessing fetal lung maturity is typically done when there is a risk of preterm delivery. In this scenario, the client is already at 38 weeks of gestation, which is considered full term. The immediate concern is the heavy, red vaginal bleeding.
Correct Answer is C
Explanation
Choice A rationale
A negative rubella titer indicates that the client does not have immunity to the rubella virus. Therefore, the statement that the client is immune to the rubella virus is incorrect.
Choice B rationale
While it is true that a person with a negative rubella titer needs a rubella vaccination, it is not recommended to administer the vaccine immediately during pregnancy due to the potential risks to the fetus. Therefore, this statement is not correct in this context.
Choice C rationale
The correct interpretation of a negative rubella titer in an antepartum client is that the client should receive a rubella immunization post-delivery. This is because rubella can cause serious complications if contracted during pregnancy, including congenital rubella syndrome in the newborn. Vaccination post-delivery will protect the client in future pregnancies.
Choice D rationale
A negative rubella titer does not provide information about whether the client is currently infected with the rubella virus. It only indicates that the client does not have immunity to the virus. Therefore, this statement is not a correct interpretation of the data.
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