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 ["A","C","D"]
Explanation
Choice A rationale:
The nurse should report the blood pressure findings to the provider because there is a significant increase in both systolic and diastolic blood pressure. At 0900, the blood pressure was 156/90 mm Hg, and at 1000, it increased to 160/96 mm Hg. This significant elevation in blood pressure can be a cause for concern as it may indicate the development of gestational hypertension or preeclampsia, which can be dangerous for both the client and the fetus.
Choice B rationale:
Cerebral manifestations are not mentioned in the nurse's notes or vital signs and are not relevant to the given scenario. Therefore, this choice is not applicable in this case.
Choice C rationale:
The nurse should report the fetal heart rate findings to the provider because it is not included in the vital signs section of the nurse's notes. Monitoring the fetal heart rate is essential to ensure the well-being of the fetus, and any abnormalities or changes in the fetal heart rate should be promptly reported to the healthcare provider for further evaluation.
Choice D rationale:
The nurse should report the respiratory rate findings to the provider. Although the respiratory rate seems to be within the normal range (22/min at 0900 and 21/min at 1000), it is a vital sign that should be closely monitored in pregnant clients. Any sudden changes or abnormalities in the respiratory rate may indicate respiratory distress or other health issues that need medical attention. Choices E and F rationale: Deep tendon reflexes and gastrointestinal assessment findings are not mentioned in the nurse's notes or vital signs. These options are not applicable in this scenario and do not require reporting to the provider.
Correct Answer is C
Explanation
The correct answer is choice C. Assist the client to breathe into a paper bag.
Choice A rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.
Choice B rationale:
Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.
Choice C rationale:
Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.
Choice D rationale:
Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.
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