A nurse is caring for a client who is at 37 weeks of gestation and has 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?

"There is an increased risk of introducing infection.”

"This could initiate preterm labor.”

"This could result in profound bleeding.”

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

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While there is a risk of infection with any internal examination, it is not the primary reason for avoiding internal examinations in a client with placenta previa. The main concern is avoiding trauma to the placenta, which could result in significant bleeding.

Choice B rationale:

Although internal examinations may potentially stimulate uterine contractions, leading to preterm labor in some cases, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.

Choice C rationale:

The correct explanation for the nurse to provide is that an internal examination could result in profound bleeding. Placenta previa occurs when the placenta partially or completely covers the cervix, and any manipulation of the cervix or uterus through an internal examination could disrupt the placenta and cause severe bleeding, endangering both the mother and the baby.

Choice D rationale:

While there is a risk of rupturing the membranes during an internal examination, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.

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Correct Answer is B

Explanation

Choice A rationale:

Hyporeactivity is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and signs of withdrawal, which are opposite to a hypo- reactive state.

Choice B rationale:

An excessive high-pitched cry is a hallmark sign of neonatal abstinence syndrome. Babies exposed to drugs like methadone during pregnancy can experience withdrawal symptoms, including a distinct high-pitched cry.

Choice C rationale:

Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to NAS. It is caused by immature peripheral circulation and usually resolves on its own.

Choice D rationale:

A respiratory rate of 50/min is within the normal range for a newborn and is not a sign of neonatal abstinence syndrome. NAS symptoms are related to drug withdrawal and not respiratory issues.

A. The fetal head is in the left occiput posterior position. B. The largest fetal diameter has passed through the pelvic outlet. C. The posterior fontanel is palpable. D. The lowermost portion of the fetus is at the level of the ischial spines.

Correct Answer is D

Explanation

Choice A rationale:

The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.

Choice B rationale:

The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.

Choice C rationale:

The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.

Choice D rationale:

This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.

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A nurse is caring for a client who is at 37 weeks of gestation and has 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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

Correct Answer is B

Explanation

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Correct Answer is D

Explanation

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

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Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?

A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

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