A nurse is caring for a client who has a placenta previa.
Which of the following findings should the nurse expect?
Spotting.
Nausea.
Board-like abdomen.
Delayed menses.
The Correct Answer is A
Choice A rationale:
Spotting is a common finding in placenta previa. It occurs due to the abnormal implantation of the placenta over or near the cervical os, leading to vaginal bleeding. This bleeding can range from mild spotting to severe hemorrhage and is a significant sign of placenta previa.
Choice B rationale:
Nausea is not a specific sign of placenta previa. Nausea and vomiting are common symptoms during early pregnancy but are not directly related to placenta previa.
Choice C rationale:
A board-like abdomen is a sign of peritonitis or an acute abdomen, which is not associated with placenta previa. This finding suggests intra-abdominal inflammation and is unrelated to the condition in question.
Choice D rationale:
Delayed menses is a common sign of pregnancy, but it does not specifically indicate placenta previa. Placenta previa is characterized by vaginal bleeding, which is not synonymous with a delay in menstrual periods.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Privately interview the client about the injuries.
Choice A rationale:
Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.
Choice B rationale:
Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.
Choice C rationale:
Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.
Choice D rationale:
Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.
Correct Answer is D
Explanation
The correct answer is choice d.
Choice A rationale:
Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.
Choice B rationale:
Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.
Choice C rationale:
While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.
Choice D rationale:
Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.
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