A nurse is assisting with the admission of a client who is at 8 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Initiate an IV infusion of magnesium sulfate.

Administer antibiotics.

Request the RN perform a cervical examination.

Prepare for cesarean birth.

Answer and Explanation

The Correct Answer is C

Choice A:
Magnesium sulfate is a medication primarily used to prevent or manage seizures in women with preeclampsia or eclampsia, conditions characterized by high blood pressure and protein in the urine during pregnancy. It is not indicated for heavy vaginal bleeding in early pregnancy.
Administration of magnesium sulfate without a clear indication could potentially lead to adverse effects such as respiratory depression, decreased deep tendon reflexes, and cardiac arrhythmias.

Choice B:
Antibiotics are used to treat bacterial infections. While heavy vaginal bleeding can sometimes be a sign of infection, it is not the primary cause of bleeding in early pregnancy.
Indiscriminate use of antibiotics without a confirmed bacterial infection can contribute to antibiotic resistance and potentially mask the underlying cause of the bleeding.

Choice D:
Cesarean birth is a major surgical procedure that is typically reserved for situations where there is a risk to the mother or fetus, such as fetal distress, failure to progress in labor, or placental abruption.
It is not indicated as the first-line intervention for heavy vaginal bleeding in early pregnancy, as there are other less invasive diagnostic and management options available.

Choice C:
A cervical examination allows the healthcare provider to assess the condition of the cervix, including its dilation and effacement, as well as to potentially identify any sources of bleeding, such as cervical polyps or lesions.
This information is crucial in determining the appropriate course of management for the patient.
It can help differentiate between potential causes of bleeding, such as threatened miscarriage, inevitable miscarriage, or ectopic pregnancy.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

Tachycardia, or a fast heart rate, is not a common finding in severe preeclampsia. While some women with preeclampsia may experience a slight increase in heart rate, it is not typically a significant or defining feature of the condition. In fact, some women with severe preeclampsia may even experience a slightly decreased heart rate due to increased vagal tone.

Choice B rationale:
Hypotension, or low blood pressure, is also not a typical finding in severe preeclampsia. Blood pressure is often elevated in preeclampsia, and it is one of the key diagnostic criteria. Hypotension would be a concerning finding in a woman with preeclampsia, as it could indicate a serious complication such as placental abruption or HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).

Choice C rationale:
Polyuria, or excessive urination, is not a characteristic finding of severe preeclampsia. In fact, many women with preeclampsia experience oliguria, or decreased urine output, due to decreased kidney function. This is because preeclampsia can cause damage to the blood vessels in the kidneys, impairing their ability to filter blood and produce urine.

Choice D rationale:
Headache is a common and often severe symptom of severe preeclampsia. It is thought to be caused by increased pressure within the brain due to swelling and vasoconstriction of the blood vessels. Headaches in preeclampsia can be very intense and may be accompanied by other symptoms such as blurred vision, nausea, and vomiting. They are often a sign that the preeclampsia is worsening and that delivery may be necessary.

A. The test predicts fetal well-being in the third trimester. B. The nurse will initiate an IV prior to the test. C. The client will need to be NPO for 8 hours prior to the test. D. The test determines the estimated date of birth.

Correct Answer is A

Explanation

Choice A:
Purpose of the Biophysical Profile (BPP): The BPP is a non-invasive test that combines ultrasound and fetal heart rate monitoring to assess fetal well-being, specifically in the third trimester of pregnancy. It evaluates five parameters: fetal breathing movements, fetal body movements, fetal tone, amniotic fluid volume, and fetal heart rate reactivity. Each parameter is assigned a score of 0 or 2, resulting in a total score of 0 to 10. A score of 8 or 10 is generally considered reassuring of fetal well-being, while a score of 6 or below may warrant further evaluation or intervention.
Timing of BPP: It's typically performed in the third trimester, often after 32 weeks of gestation, when the fetus has developed regular sleep-wake cycles and breathing movements.
Risk Assessment: It's often recommended for pregnancies considered high-risk, such as those with: Maternal diabetes
Preeclampsia
Decreased fetal movement Past stillbirth
Multiple gestation
Oligohydramnios (low amniotic fluid) Post-term pregnancy (over 42 weeks)

Choice B:
IV initiation is not a routine part of BPP: Intravenous (IV) access is not typically required for a BPP. The test involves external monitoring of fetal heart rate and ultrasound imaging, which do not necessitate IV access.

Choice C:
NPO status is not necessary: The client does not need to be NPO (nothing by mouth) for a BPP. There are no dietary restrictions or fasting requirements for this test.

Choice D:
BPP does not determine the estimated date of birth: The primary purpose of the BPP is to assess fetal well-being, not to determine the estimated date of delivery (EDD). The EDD is typically established based on the last menstrual period or early ultrasound measurements.

View Question and Answer

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

A nurse is assisting with the admission of a client who is at 8 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

A nurse is caring for a client who is pregnant and has suspected placenta previa. Which of the following should the nurse monitor the client for?

A nurse is reinforcing nutrition teaching with a client during the first prenatal visit. Which of the following statements by the client indicates understanding of the teaching?

A nurse is reinforcing teaching about nutritional needs with a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase during pregnancy?

A nurse is reinforcing teaching with a client who is at weeks of gestation and scheduled for a non-stress test (NST). Which of the following statements by the client indicates a need for further teaching?

A nurse is assisting with the care of a client who is in active labor at 9 weeks of gestation. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

A nurse is teaching a client who is scheduled for a non-stress test. Which of the following information should the nurse include? Choice Options:

A nurse is caring for a 22-year-old female client who is experiencing lower abdominal pelvic pain. The client is at risk of developing a condition due to a finding.