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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice D rationale:

The correct answer is Choice D. The biophysical profile is a prenatal test used to assess fetal well-being in the third trimester of pregnancy. It is not used to determine the estimated date of birth (Choice A), as that is typically calculated based on the first day of the last menstrual period and confirmed or adjusted by early ultrasounds.

The test also does not require the client to be NPO (nothing by mouth) for 8 hours prior to the test (Choice B). This restriction is commonly associated with certain medical procedures, but it is not applicable to the biophysical profile.

Furthermore, there is no need to initiate an IV (intravenous line) before the biophysical profile (Choice C). The test is non-invasive and involves the use of ultrasound and fetal heart rate monitoring. The biophysical profile assesses several fetal parameters, such as fetal movement, fetal tone, fetal breathing movements, amniotic fluid volume, and the fetal heart rate. These parameters help evaluate the well-being and health of the baby. The test is often recommended in cases of high-risk pregnancies, decreased fetal movement, or other conditions that may warrant closer monitoring of the baby's condition. By knowing that the biophysical profile predicts fetal well-being in the third trimester, the nurse can provide accurate information to the client, reassuring them about the health of their baby and explaining the importance of the test in ensuring a safe delivery and healthy outcome.

A. Vaginal hematoma. B. Hypoglycemia. C. Chorioamnionitis. D. Uterine hemorrhage. E. Dehiscence.

Correct Answer is D

Explanation

Choice A rationale:

Vaginal hematoma is not a common complication in the 4th stage of labor. This stage primarily involves the recovery and stabilization of the mother after delivery.

Choice B rationale:

Hypoglycemia is not a typical complication in the 4th stage of labor. While blood glucose levels might be monitored during labor, the risk of hypoglycemia is generally higher in neonates, especially if the mother has diabetes.

Choice C rationale:

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, typically diagnosed during labor or shortly after delivery. It is not specific to the 4th stage of labor.

Choice D rationale:

Uterine hemorrhage is the most significant concern during the 4th stage of labor, also known as the "postpartum”. or "recovery”. stage. It refers to excessive bleeding from the site where the placenta detached. This bleeding can be life-threatening if not managed promptly.

Choice E rationale:

Dehiscence is the separation of surgical incisions, which is not a common complication during the 4th stage of labor.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

When contributing to the plan of care for the 4th stage of labor, the nurse should recognize the client is at the greatest risk of developing which of the following complications?

Correct Answer is D

Explanation

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