A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary rationale the nurse should avoid performing a pelvic examination?
Preterm labor.
Infection.
Profound bleeding.
Rupture of the fetal membranes.
The Correct Answer is C
Choice A rationale:
Preterm labor. Performing a pelvic examination in a client with placenta previa can potentially trigger uterine contractions, leading to preterm labor. Manipulating the cervix during the examination may stimulate the release of hormones that could initiate labor, putting both the mother and the baby at risk.
Choice B rationale:
Infection. While infection is a valid concern in any medical procedure, it is not the primary rationale for avoiding a pelvic examination in a client with placenta previa. The primary concern is the risk of severe bleeding caused by the disruption of the placenta's attachment to the uterine wall.
Choice C rationale:
Profound bleeding. The primary rationale to avoid a pelvic examination in a client with placenta previa is the risk of profound bleeding. Placenta previa occurs when the placenta covers part or all of the cervix, and it is at risk of being damaged or detached during a pelvic exam. This can lead to life-threatening hemorrhage for both the mother and the baby.
Choice D rationale:
Rupture of the fetal membranes. While this complication is possible during a pelvic examination, it is not the primary rationale to avoid the procedure in a client with placenta previa. The main concern, as mentioned before, is the risk of severe bleeding that can occur due to placental disruption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Fetal head compression is unlikely to cause variable decelerations in the fetal heart rate. During contractions and labor, the fetal head may experience pressure, but this usually leads to early decelerations, not variable decelerations. Early decelerations are considered benign and are caused by the head's pressure stimulating the vagus nerve, resulting in a temporary decrease in heart rate.
Choice B rationale:
nature.
Choice C rationale:
Maternal opioid administration is not a direct cause of variable decelerations in the fetal heart rate. While opioids can cross the placenta and may affect the fetus, they are more likely to cause other issues, such as respiratory depression in the newborn, rather than variable decelerations.
Choice D rationale:
Uteroplacental insufficiency is not the primary factor causing variable decelerations. Uteroplacental insufficiency refers to an inadequate blood flow and oxygen delivery to the placenta, which c
Correct Answer is B
Explanation
The correct answer is choice B. Assure the client that the score is within the expected range.
Choice A rationale:
Administering oxygen and notifying the provider is not necessary for a biophysical profile (BPP) score of 10. A score of 10 indicates that the fetus is well-oxygenated and there are no signs of distress.
Choice B rationale:
A BPP score of 10 is considered normal and reassuring, indicating that the fetus is well-oxygenated and there are no signs of distress. Therefore, the nurse should assure the client that the score is within the expected range.
Choice C rationale:
Offering the client orange juice and repeating the assessment in 1 hour is not necessary for a BPP score of 10. This action might be considered if the score were lower and there was a need to reassess fetal well-being.
Choice D rationale:
Assisting the client into a side-lying position is not required for a BPP score of 10. This position is typically recommended to improve uteroplacental blood flow in cases of fetal distress or lower BPP scores.
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