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 C
Explanation
Choice A rationale:
Current guidelines recommend that women aged 21 to 29 have a Pap test every three years, and those aged 30 to 65 can either have a Pap test every three years or a Pap plus HPV (human papillomavirus) test every five years. After age 65, and with a history of normal results, Pap tests may be discontinued.
Choice B rationale:
The nurse should not include choice B, "Pap tests are discontinued following removal of the ovaries,” in the teaching. The presence or absence of ovaries does not affect the need for Pap testing. The Pap test is primarily used to screen for cervical cancer, and its necessity is determined based on age and previous screening results, not on ovarian status.
Choice C rationale:
Patients are advised to avoid sexual intercourse, douching, or using vaginal medications for 24 hours before the test to ensure accurate results.
Choice D rationale:
The nurse should not include choice D, "Viral infections can be detected by a Pap test,” in the teaching. The Pap test is not designed to detect viral infections. Instead, it is used to detect abnormal cervical cells, which may indicate pre-cancerous or cancerous changes.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should plan to administer Ampicillin to the client with a group B streptococcus (GBS) B-hemolytic infection. Ampicillin is the first-line antibiotic treatment for intrapartum prophylaxis in GBS-positive pregnant women. It helps prevent the transmission of the bacteria from the mother to the newborn, reducing the risk of early-onset GBS infection in the infant.
Choice B rationale:
Azithromycin is not the appropriate choice for treating GBS B-hemolytic infection during labor. While Azithromycin is effective against certain bacteria, it is not the recommended antibiotic for GBS prophylaxis in labor. Ampicillin or Penicillin is the preferred medication in this scenario.
Choice C rationale:
Ceftriaxone is not the appropriate medication for treating GBS B-hemolytic infection during labor. Ceftriaxone belongs to the cephalosporin class of antibiotics and is not the first-line treatment for GBS prophylaxis. Ampicillin or Penicillin is the preferred choice.
Choice D rationale:
Acyclovir is an antiviral medication and is not indicated for the treatment of GBS B-hemolytic infection. GBS is a bacterial infection, and antiviral medications like Acyclovir do not have an effect on bacteria.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
