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
Instructing the client to avoid alcohol for 72 hr after treatment is a common instruction given when a client is prescribed certain medications, such as metronidazole, due to the potential for a disulfiram-like reaction. However, this choice does not directly address the client’s symptoms of inflamed labia majora and minora and a large amount of frothy, yellow-green, malodorous discharge.
Choice B rationale
The client’s symptoms are indicative of Trichomoniasis, a sexually transmitted infection caused by a parasite. Metronidazole is a medication commonly used to treat this infection. A single dose of 2 g orally is a typical treatment regimen.
Choice C rationale
An oatmeal sitz bath can help soothe irritated skin and reduce inflammation, but it does not treat the underlying cause of the client’s symptoms.
Choice D rationale
Recommending the client’s partner receive treatment is important in cases of sexually transmitted infections to prevent reinfection. However, this choice does not directly address the client’s immediate need for treatment.
Correct Answer is C
Explanation
Choice A rationale
While it’s important for the nurse to provide reassurance and support during the exam, this statement alone doesn’t address the client’s specific concerns or provide any useful information.
Choice B rationale
Telling the client to relax doesn’t address her concerns or provide any useful information. It’s normal to feel nervous before a pelvic exam, especially if it’s the first one.
Choice C rationale
Asking the client what part of the exam makes her most nervous allows the nurse to provide specific information and reassurance, which can help alleviate the client’s anxiety.
Choice D rationale
While a pelvic exam is often part of the process when starting oral contraceptives, it’s not always required. The need for a pelvic exam can depend on the client’s age, sexual history, and other factors.
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