A nurse is assisting with the care of a client who is at 28 weeks of gestation.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Potential Condition: Placenta previa
- This condition is characterized by the placenta covering the cervix, which can lead to painless, bright red vaginal bleeding during the second or third trimester.
- Actions to Take:
1. Insert a large-bore peripheral IV catheter.
- This is a precautionary measure to ensure that there is immediate venous access for fluid and blood product administration if necessary.
2. Reinforce with the client to maintain bed rest.
- Limiting physical activity can help reduce the risk of further bleeding.
- Parameters to Monitor:
1. Vaginal bleeding
- Monitoring the amount, color, and frequency of bleeding is crucial to assess the ongoing blood loss and stability of the condition.
2. Fetal well-being
- Regular monitoring of fetal heart rate and movement is important to ensure the fetus is not in distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased muscle tone is not a typical manifestation of neonatal abstinence syndrome. Symptoms of neonatal abstinence syndrome usually include increased muscle tone and irritability.
B. An exaggerated Moro reflex is a sign of neonatal abstinence syndrome. This reflex can be more pronounced in infants experiencing withdrawal from substances.
C. A weak cry is not characteristic of neonatal abstinence syndrome. Infants with this syndrome may have a high-pitched, excessive, or persistent cry.
D. Neonates with abstinence syndrome are difficult to console. They may have persistent crying and be hard to calm, which contrasts with the ability to console easily.
Correct Answer is A
Explanation
A. Feeding sessions typically last 20 to 30 minutes, allowing the newborn to feed at a comfortable pace and promoting bonding.
B. Formula remaining in the bottle after feeding should be discarded because bacteria from the infant’s mouth can contaminate it; it should not be refrigerated for reuse.
C. Prepared formula can be safely stored in the refrigerator for up to 48 hours only if it has not been fed to the infant; however, once offered, it must be discarded after the feeding.
D. The newborn should be burped periodically during the feeding, such as halfway through and at the end, to reduce swallowed air and discomfort.
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