A nurse is caring for a 32-year-old female 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 []

Condition: The client is most likely expeíiencing Placenta píevia. This condition is chaíacteíized by painless, bíight íed vaginal bleeding duíing the thiíd tíimesteí, which matches the client’s symptoms.
Actions:

1. Instíuct the client to maintain bed íest: This can help to píevent fuítheí bleeding.
2. Píepaíe the client foí a possible ultíasound: An ultíasound can help to confiím the diagnosis and assess the placental location and fetal well-being.

Paíameteís to Monitoí:

1. Ïetal heaít íate: Monitoíing the fetal heaít íate can help to assess the baby’s well-being.
2. Hemoglobin and hematocíit levels: These should be monitoíed to assess the client’s blood loss and íisk of anemia.

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Correct Answer is A

Explanation

Choice A rationale
Facial petechiae are small, pinpoint, red or purple spots on the skin that result from minor bleeding from broken capillary blood vessels. They can occur as a result of a nuchal cord, which is when the umbilical cord becomes wrapped around the fetus’s neck. This can cause pressure and minor injuries, leading to the appearance of petechiae.
Choice B rationale
Periauricular papillomas are not typically associated with a nuchal cord. They are small, benign skin growths that occur near the ear. They are not a common finding in newborns and are not related to the conditions of birth.
Choice C rationale
Erythema toxicum is a common rash seen in newborns, characterized by tiny bumps surrounded by an area of red skin. It is not specifically associated with a nuchal cord.
Choice D rationale
Telangiectatic nevi, also known as “stork bites,” are common birthmarks seen in newborns, characterized by patches of pink or red skin. They are not specifically associated with a nuchal cord.

A. The client is changing the perineal pad once daily. B. The client cleans the perineum with a squeeze bottle after urinating. C. The client’s perineal suture line is well approximated. D. The client is using witch hazel pads on the perineum.

Correct Answer is A

Explanation

Choice A rationale

Changing the perineal pad only once daily can lead to an increased risk of infection, which can delay wound healing. It’s important to maintain cleanliness in the perineal area, especially after a laceration, to promote healing.
Choice B rationale
Cleaning the perineum with a squeeze bottle after urinating is actually a recommended practice. It helps to keep the area clean and reduce the risk of infection.
Choice C rationale
A well-approximated perineal suture line is a positive sign of healing. It indicates that the edges of the wound are close together, which promotes healing and reduces the risk of infection.
Choice D rationale
Using witch hazel pads on the perineum can provide relief from discomfort and has astringent properties that can promote healing.

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Naxlex Comprehensive Predictor Exams

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. What clinical findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum and has a perineal laceration. What findings place the client at risk for delayed wound healing?

Correct Answer is A

Explanation

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