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A nurse is assisting with the care of a client who is at 28 weeks of gestation.

Exhibits

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.

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

A. Insert the suppository 5 cm (2 in) is incorrect. The suppository should be inserted about 2-3 inches into the vaginal canal, not specifically 5 cm, but the exact depth may vary.
B. Insert the suppository along the posterior vaginal wall is correct. Inserting the suppository along the posterior vaginal wall helps ensure it reaches the area where it is needed for effective treatment.
C. Apply petroleum jelly to the suppository is incorrect. The suppository should not be coated with petroleum jelly; it should be used as is to avoid interference with its absorption and effectiveness.
D. Assist the client into a prone position is incorrect. The client should be assisted into a supine position with knees bent or into a lithotomy position for the insertion of the suppository, not a prone position.

Correct Answer is A

Explanation

A. Group B Streptococcus (GBS) status is typically re-evaluated at around 36 weeks of gestation to determine if prophylactic antibiotics are needed during labor to prevent transmission to the baby.
B. A positive GBS test does not automatically indicate a cesarean birth. Intravenous antibiotics during labor are generally used to prevent transmission of GBS to the newborn.
C. GBS infection can cause serious complications in newborns, but hearing loss is not a typical outcome. The primary concerns are sepsis, pneumonia, and meningitis.
D. Antibiotics for GBS are given during labor, not the last two weeks of pregnancy. The treatment aims to reduce the risk of GBS transmission to the baby during delivery.

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