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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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 vaginal itching and discharge.
Choice B rationale
The client’s symptoms are indicative of Bacterial Vaginosis (BV), a common vaginal infection in women of reproductive age. 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
Douching is generally not recommended as it can disrupt the normal balance of bacteria in the vagina and can lead to further complications.
Choice E 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 A
Explanation
Choice A rationale
High-absorbency tampons are a known risk factor for toxic shock syndrome (TSS). TSS is a rare, life-threatening complication of certain types of bacterial infections. Often TSS results from toxins produced by Staphylococcus aureus (staph) bacteria, but the condition may also be caused by toxins produced by group A streptococcus (strep) bacteria. The condition is caused due to bacterial toxins from Streptococcus or Staphylococcus infection. Bacteria usually enter the body through openings in the skin such as wounds or cuts. The risk factors include open skin wound, having had recent surgery, using superabsorbent tampons or contraceptive sponges. Therefore, the nurse should include the use of high-absorbency tampons in the teaching as increasing the risk for contracting TSS.
Choice B rationale
Travel to foreign countries is not specifically mentioned as a risk factor for TSS. While traveling can expose individuals to a variety of health risks depending on the destination, it is not directly linked with an increased risk of TSS1234.
Choice C rationale
Mosquito bites are not a known risk factor for TSS. Mosquito bites can transmit certain diseases such as malaria, dengue fever, and Zika virus, but they are not associated with TSS1234.
Choice D rationale
Having multiple sexual partners can increase the risk of sexually transmitted infections, but it is not a known risk factor for TSS. TSS is typically associated with superabsorbent tampon use, skin wounds, and recent surgery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.