A nurse is caring for a client who is at 37 weeks of gestation and diagnosed with placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

"This could result in profound bleeding."

"This could initiate preterm labor."

"There is an increased risk of rupture of the membranes."

"There is an increased risk of introducing infection."

Answer and Explanation

The Correct Answer is A

Explanation:

A. "This could result in profound bleeding."

This is the correct explanation. Placenta previa involves the placenta partially or completely covering the cervix. Performing an internal examination, such as a vaginal exam, can disrupt the placenta and lead to severe bleeding. This bleeding can be dangerous for both the mother and the baby, making it a critical concern to avoid internal exams in placenta previa cases.

B. "This could initiate preterm labor."

While internal examinations may trigger preterm labor in some cases, the primary concern in placenta previa is the risk of significant bleeding. Preterm labor is not typically the primary reason for avoiding internal exams in placenta previa; instead, the focus is on preventing bleeding and its associated complications.

C. "There is an increased risk of rupture of the membranes."

While an internal examination may carry a risk of membrane rupture, especially in situations with low-lying placenta or marginal previa, the primary concern in placenta previa is the potential for severe bleeding if the placenta is disturbed. Rupture of membranes is a consideration but is not the main reason for avoiding internal exams in placenta previa.

D. "There is an increased risk of introducing infection."

While infection is a concern with any invasive procedure, including internal examinations, it is not typically the primary reason for avoiding internal exams in placenta previa. The main focus is on preventing bleeding complications that can arise from disrupting the placenta.

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Correct Answer is C

Explanation

Explanation:

A. Shortly after giving birth

This timing is not recommended for rubella immunization during pregnancy. Rubella vaccination should ideally occur before conception or during the postpartum period, but not immediately after giving birth.

B. Immediately

Immunization for rubella is not typically recommended immediately during pregnancy. It is preferred to administer rubella vaccination before pregnancy or during the postpartum period.

C. During her next attempt to get pregnant

This option is closer to the recommended timing. Women who lack immunity to rubella should receive the rubella vaccine after giving birth but before attempting to get pregnant again. This approach helps ensure protection against rubella during future pregnancies.

D. In the third trimester

Administering rubella immunization during the third trimester of pregnancy is not recommended. Vaccination against rubella should ideally occur either before pregnancy or after delivery, as giving it during pregnancy can pose risks to the fetus.

A. Assess maternal blood glucose. B. Place the client in Trendelenburg position. C. Prepare for an emergency cesarean birth. D. Discontinue the medication infusion.

Correct Answer is D

Explanation

Explanation:

A. Assess maternal blood glucose:

While assessing blood glucose levels is important in clients receiving magnesium sulfate due to its potential effects on blood sugar, it is not the priority action in this scenario. The client's respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity, which can lead to respiratory depression and neuromuscular effects. Therefore, the immediate concern is addressing the magnesium toxicity rather than assessing blood glucose levels.

B. Place the client in Trendelenburg position:

Placing the client in Trendelenburg position is not indicated for magnesium toxicity. The Trendelenburg position involves placing the client in a supine position with the legs elevated higher than the head. While this position may be used in some situations (e.g., hypotension), it is not appropriate for treating magnesium toxicity, respiratory depression, or absent deep-tendon reflexes. Placing the client in Trendelenburg position may worsen respiratory function and is not recommended in this case.

C. Prepare for an emergency cesarean birth:

While severe preeclampsia or eclampsia may necessitate emergency cesarean birth in some cases, it is not the immediate action needed for a client experiencing respiratory depression and absent deep-tendon reflexes due to magnesium sulfate toxicity. Cesarean birth is not the appropriate response to magnesium toxicity and would not address the client's current respiratory and neuromuscular issues. Therefore, preparing for an emergency cesarean birth is not the correct action in this scenario.

D. Discontinue the medication infusion:

This is the correct action to take. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Magnesium sulfate, while effective in preventing seizures in preeclampsia, can lead to respiratory depression and affect neuromuscular function at toxic levels. Discontinuing the medication infusion is crucial to prevent further magnesium toxicity and adverse effects on the client's respiratory and neuromuscular status. It is the immediate and priority action needed to address the client's current condition.

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A nurse is caring for a client who is at 37 weeks of gestation and diagnosed with placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?

Correct Answer is C

Explanation

A nurse is caring for a client diagnosed with preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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