A nurse is caring for a client who has placenta previa. Which of the following interventions should the nurse implement for this client? (Select all that apply.)
Perform a vaginal exam.
Monitor fetal heart rate with an internal fetal monitor.
Frequently assess maternal heart rate.
Initiate bed rest with bathroom privileges.
Correct Answer : C,D,E
The correct answers are C, D, E.
Choice A reason:
Performing a vaginal exam is contraindicated in placenta previa because it can disrupt the placenta and cause significant bleeding.
Choice B reason:
Monitoring fetal heart rate with an internal fetal monitor is not recommended as it involves a vaginal exam, which poses a risk of bleeding in placenta previa cases.
Choice C reason:
Frequently assessing maternal heart rate is important to detect any changes that could indicate maternal hemorrhage or other complications.
Choice D reason:
Initiating bed rest with bathroom privileges is advised to minimize the risk of bleeding and to ensure the safety of both the mother and the fetus.
Choice E reason:
Having oxygen equipment available is essential to manage potential fetal distress, which can occur with placenta previa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Premature ovarian failure affects the ovaries and leads to early menopause, resulting in the loss of the woman's reproductive ability. This condition can cause infertility due to the depletion or dysfunction of eggs in the ovaries, hindering conception.
Choice B rationale:
Renal calculi (kidney stones) do not directly impact fertility. It is a condition unrelated to the reproductive system.
Choice C rationale:
Dysmenorrhea refers to painful menstruation and, while it can be uncomfortable, it does not necessarily affect fertility.
Choice D rationale:
Recurrent urinary tract infections may be a concern for overall health but do not necessarily directly impact fertility unless there are severe complications. They are unrelated to infertility assessment.
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
Edema is not an expected finding of uncomplicated gestational hypertension. While some degree of edema can be common during pregnancy, it is not specifically related to gestational hypertension.
Choice B rationale:
A blood pressure reading of 155/92 is an expected finding in a client with uncomplicated gestational hypertension. Gestational hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg after 20 weeks of pregnancy, without the presence of proteinuria or other organ dysfunction.
Choice C rationale:
Proteinuria is an expected finding in gestational hypertension. It is an important diagnostic criterion for preeclampsia, which is a severe form of gestational hypertension.
Choice D rationale:
Hepatic dysfunction is not an expected finding in uncomplicated gestational hypertension. Hepatic dysfunction would indicate more severe complications such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count), which is a medical emergency.
Choice E rationale:
Blood pressure usually returns to normal after pregnancy in women with uncomplicated gestational hypertension. However, it is essential to monitor the client closely postpartum to ensure blood pressure normalization.
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