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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Vitamin E is important for overall health but does not need to be specifically increased during pregnancy.
B. Vitamin D supports calcium absorption, but routine intake is generally sufficient unless a deficiency exists.
C. Fiber intake should be increased during pregnancy to help prevent constipation, which is a common issue due to hormonal changes and slowed gastrointestinal motility.
D. Calcium intake is important, but for many clients, standard dietary recommendations are adequate unless otherwise prescribed.

A. Gravida 3, Para 2. B. Gravida 3, Para 3. C. Gravida 4, Para 2. D. Gravida 4, Para 3.

Correct Answer is C

Explanation

Choice A rationale:

Gravida refers to the number of times a woman has been pregnant, and Para indicates the number of pregnancies that have reached viability (at least 20 weeks) Since the client has

been pregnant for the fourth time and delivered two full-term newborns (reached viability), she is gravida 4, and since she had one spontaneous abortion (miscarriage) at 10 weeks of gestation, she is para 2 (two pregnancies reached viability)

Choice B rationale:

This choice would be incorrect because it indicates that the client has had three pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.

Choice C rationale:

This is the correct choice, as explained above. Choice D rationale:

This choice would be incorrect because it indicates that the client has had four pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.

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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.)

Nursing Test Bank

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