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"]
Explanation
A. Douching is not recommended as it can disrupt the natural vaginal flora and potentially lead to further infections. Instead, maintaining good hygiene without douching is advised.
B. Urinating before bedtime is actually recommended to help flush out bacteria from the urinary tract. Avoiding urination at bedtime can increase the risk of developing a urinary tract infection.
C. Bubble baths can irritate the vaginal area and increase the risk of a urinary tract infection. Pregnant clients should be advised to avoid bubble baths and use mild, unscented soaps instead.
D. Yogurt products are beneficial because they contain probiotics that can help maintain a healthy balance of bacteria in the vagina and urinary tract. Eliminating yogurt from the diet is not necessary and may be counterproductive.
E. Wearing cotton-crotch underwear helps keep the vaginal area dry and reduces the risk of infections. Cotton allows for better air circulation and absorbs moisture compared to synthetic fabrics.
Correct Answer is B
Explanation
A. The lancet should be used on the outer aspect of the heel, not the inner aspect, to avoid injury to the heel's bone and nerves. Proper technique for heel puncture is critical for successful specimen collection.
B. Warming the newborn’s heel for 5 to 10 minutes before the puncture helps to increase blood flow and ensure a sufficient blood sample for screening tests. This is a recommended practice to improve the effectiveness of the heel stick.
C. Applying an antiseptic to the heel before the puncture is correct practice, but applying it after the specimen is collected is not recommended. It can cause stinging and potentially interfere with the blood sample.
D. After the puncture, the heel should be gently massaged and then covered with a bandage to stop bleeding. Leaving the heel open to the air is not recommended as it can lead to infection or continue bleeding.
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