A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?
Placenta previa.
Preterm labor.
Threatened abortion.
Abruptio placentae.
The Correct Answer is A
Choice A rationale:
Painless, bright red vaginal bleeding at 36 weeks gestation is indicative of placenta previa. Placenta previa is a condition in which the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to efface and dilate. The bright red color of the blood is due to its fresh origin from the exposed placental vessels. This condition is painless because the bleeding occurs without uterine contractions.
Choice B rationale:
Preterm labor is not the correct answer in this scenario. Preterm labor refers to the onset of regular uterine contractions leading to cervical changes before 37 weeks of gestation. In this case, the key indicator is painless bleeding, which is not associated with uterine contractions.
Choice C rationale:
Threatened abortion is also not the correct answer. Threatened abortion is the term used when a pregnant woman experiences vaginal bleeding, but the cervix is closed, indicating that there is still a chance for the pregnancy to continue. However, the bleeding in placenta previa is unrelated to fetal viability and is specifically caused by the placental position.
Choice D rationale:
Abruptio placentae is not the correct answer either. Abruptio placentae, also known as placental abruption, is a condition where the placenta prematurely separates from the uterine wall before delivery. This can cause painful bleeding due to the blood being trapped between the placenta and uterine wall. In the given scenario, the bleeding is described as painless, which does not align with the characteristics of abruptio placentae.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F"]
Explanation
Choice A rationale:
The nurse should report visual disturbances to the provider. Visual disturbances in a pregnant client could indicate potential complications such as preeclampsia or eclampsia. These conditions are characterized by high blood pressure and can be harmful to both the mother and the fetus. Reporting visual disturbances promptly allows the provider to assess the situation and take appropriate actions to ensure the safety of the client and the baby.
Choice B rationale:
The nurse should also report blood pressure changes to the provider. The client's blood pressure has increased significantly from 179/99 mm Hg to 170/101 mm Hg over a short period. High blood pressure during pregnancy can be indicative of preeclampsia, a serious condition that requires close monitoring and management to prevent complications. Reporting the blood pressure changes promptly allows the provider to evaluate the situation and intervene as needed to safeguard the client's well-being.
Choice F rationale:
The nurse should report the fetal heart rate to the provider. Monitoring the fetal heart rate is crucial in prenatal care as it helps assess the well-being of the baby. Any abnormality in the fetal heart rate could indicate fetal distress or other complications. Promptly reporting any concerning changes in the fetal heart rate enables the provider to take appropriate measures to ensure the health and safety of the baby. The other choices (C, D, and E) are not the most critical findings in this scenario. While respiratory rate (C), deep tendon reflexes (D), and weight (E) are important aspects to monitor during pregnancy, they do not raise immediate concerns for potential complications like visual disturbances, blood pressure changes, and fetal heart rate abnormalities mentioned above. Nonetheless, they should still be documented and monitored regularly as part of routine prenatal care.
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.
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