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 C,E,A,B,D
Explanation
1. Wrap a warm, moist cloth around the heel to dilate the blood vessels, which makes it easier to obtain the blood sample.
2. Cleanse the heel with an antiseptic to reduce the risk of infection at the puncture site.
3. Puncture the heel and collect the blood, ensuring that the sample is adequate for the test.
4. Apply pressure with a dry gauze pad to stop the bleeding from the puncture site.
5. Cover the heel with an adhesive bandage to protect the area and minimize the risk of infection.
Correct Answer is D
Explanation
A. A history of methicillin-resistant Staphylococcus aureus (MRSA) does not contraindicate the use of a cervical cap. MRSA is an infection issue, but the cervical cap does not pose a significant risk for MRSA-related complications.
B. A history of thrombophlebitis is not a contraindication for the use of a cervical cap. Thrombophlebitis concerns are generally associated with hormonal contraceptives rather than barrier methods like cervical caps.
C. Type 1 diabetes mellitus is not a contraindication for using a cervical cap. Individuals with Type 1 diabetes can use barrier methods for contraception, though they should manage their condition carefully for overall health.
D. A history of toxic shock syndrome (TSS) is a contraindication for using a cervical cap. TSS is a severe, potentially life-threatening condition often associated with the use of barrier methods like tampons or cervical caps, which can increase the risk of infection.
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