A nurse is assessing a client who has placenta previa and is receiving fetal monitoring.Which of the following clinical findings should the nurse expect?
Variable decelerations.
Painless vaginal bleeding.
Rigid abdomen.
Uterine tachysystole.
The Correct Answer is B
Choice A rationale
Variable decelerations are associated with umbilical cord compression, not placenta previa. In placenta previa, the placenta covers the cervical os, but it does not typically cause variable decelerations on fetal monitoring.
Choice B rationale
Painless vaginal bleeding is a hallmark sign of placenta previa. This occurs because the placenta is located near or over the cervical os, leading to bleeding when the cervix dilates or effaces.
Choice C rationale
A rigid abdomen is more indicative of placental abruption, where the placenta detaches prematurely from the uterine wall, causing pain and a tense abdomen, not typically seen in placenta previa.
Choice D rationale
Uterine tachysystole is characterized by excessive uterine contractions and is not a clinical finding related to placenta previa. Tachysystole often results from excessive oxytocin use or other uterine stimulants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Blood pressure should be assessed as opioid analgesics can cause hypotension, which can be detrimental to both mother and fetus during labor.
Choice B rationale
Fetal heart rate monitoring is essential as opioids can cross the placenta and potentially cause fetal bradycardia or distress, thus necessitating close monitoring.
Choice C rationale
Deep tendon reflexes are not commonly affected by opioid analgesics and therefore are not a primary assessment when administering these medications during labor.
Choice D rationale
Blood glucose levels are not typically influenced by opioid analgesics in the context of labor, so this is not a relevant assessment for this scenario.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why:
- Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage.
- Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss.
So, the completed sentence would be:
- The nurse should first monitor the client's fundal tone followed by the client's blood pressure.
Taking care of immediate risks and stabilizing the patient is key in such cases.
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