A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads with blood in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?
Initiation of pushing
Examination to determine cervical status
Preparation for cesarean birth
A magnesium sulfate infusion
The Correct Answer is C
Choice A reason: Initiation of pushing is not an appropriate nursing action, as it can increase the bleeding and the risk of placental separation, which can cause fetal hypoxia, hemorrhage, or shock. Pushing is contraindicated in clients with placenta previa, which is a condition where the placenta covers the cervical opening and can cause painless, bright red bleeding in the third trimester.
Choice B reason: Examination to determine cervical status is not an appropriate nursing action, as it can cause trauma and perforation of the placenta, which can lead to severe bleeding and infection. Examination is contraindicated in clients with placenta previa, unless it is confirmed by ultrasound that the placenta is not low-lying or covering the cervix.
Choice C reason: Preparation for cesarean birth is an appropriate nursing action, as it is the preferred mode of delivery for clients with placenta previa, especially if the bleeding is heavy, the fetus is mature, or the fetal distress is present. Cesarean birth can prevent the complications of placenta previa, such as fetal hypoxia, hemorrhage, or shock.
Choice D reason: A magnesium sulfate infusion is not an appropriate nursing action, as it is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, which is a hypertensive disorder of pregnancy. Magnesium sulfate is not indicated for clients with placenta previa, unless they also have severe preeclampsia or eclampsia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Placenta previa is a condition where the placenta covers the cervix partially or completely. It can cause painless vaginal bleeding, but not abdominal pain.
Choice B reason: Prolapsed cord is a condition where the umbilical cord slips through the cervix and protrudes into the vagina or beyond. It can cause fetal distress, but not abdominal pain or vaginal bleeding.
Choice C reason: Incompetent cervix is a condition where the cervix dilates prematurely and painlessly. It can cause preterm labor and delivery, but not abdominal pain or vaginal bleeding.
Choice D reason: Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery. It can cause severe abdominal pain, vaginal bleeding, and fetal distress. It is a medical emergency that requires immediate intervention.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering before 34 weeks of gestation. Betamethasone stimulates the production of surfactant, which is a substance that prevents the alveoli from collapsing and improves the lung function of the fetus.
Choice B reason: This statement is incorrect, as betamethasone does not affect the cervical dilation, which is a sign of labor progression. Betamethasone does not stop or delay labor, but rather reduces the complications of prematurity, such as respiratory distress syndrome, intraventricular hemorrhage, or necrotizing enterocolitis.
Choice C reason: This statement is incorrect, as betamethasone does not increase the fetal heart rate, which is a measure of fetal well-being. Betamethasone may cause transient fetal bradycardia, which is a decrease in the fetal heart rate, due to the increased vagal tone and blood pressure. The nurse should monitor the fetal heart rate and notify the provider if there are any signs of fetal distress.
Choice D reason: This statement is incorrect, as betamethasone is not used to stop preterm labor contractions, which are caused by the uterine muscle activity. Betamethasone does not have any tocolytic effect, which is the ability to inhibit uterine contractions. Other medications, such as magnesium sulfate, nifedipine, or indomethacin, may be used to stop preterm labor contractions.
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