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.

Answer and Explanation

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.

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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.

A. Bleeding. B. Infection. C. Potassium deficiency. D. Hyperbilirubinemia.

Correct Answer is A

Explanation

Choice A: The correct answer is (a) Bleeding. The purpose of administering vitamin K to a newborn following delivery is to prevent bleeding complications. Vitamin K plays a crucial role in the synthesis of blood clotting factors, specifically factors II, VII, IX, and X. Newborns have low levels of vitamin K at birth, and it takes a few days for their bodies to start producing it. This places them at risk of developing vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including bleeding into the brain (intracranial haemorrhage). By giving the newborn a vitamin K injection, this deficiency is corrected, reducing the risk of bleeding complications.

Choice B rationale

(b) Infection. Administering vitamin K to a newborn is not intended to prevent infections. Vitamin K is essential for blood clotting and does not have a direct role in preventing or treating infections. Infection prevention measures involve proper hygiene practices and vaccination, but vitamin K is unrelated to this aspect of care.

Choice C rationale

(c) Potassium deficiency. Administering vitamin K to a newborn has no impact on potassium levels. Potassium is a different essential nutrient that plays a vital role in various physiological processes, but it is not related to blood clotting. The administration of vitamin K is specific to preventing bleeding complications, not addressing potassium deficiency.

Choice D rationale

(d) Hyperbilirubinemia. The correct answer is not (d) Hyperbilirubinemia. Vitamin K administration is not aimed at preventing or treating hyperbilirubinemia, a condition characterized by elevated levels of bilirubin in the blood. Hyperbilirubinemia is related to the breakdown of red blood cells and the liver'sability to process bilirubin, whereas vitamin K's primary role is in the clotting cascade.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?

Correct Answer is A

Explanation

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