A nurse is caring for a patient who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes.
The nurse suspects placenta previa.
What would be an appropriate nursing action in this situation?
Administer a magnesium sulfate infusion.
Initiate pushing.
Prepare for a cesarean birth.
Examination to determine cervical status.
The Correct Answer is C
If a patient in labor at 40 weeks of gestation reports saturating two perineal pads in the past 30 minutes, and placenta previa is suspected, an appropriate nursing action would be to prepare for a cesarean birth. Placenta previa, where the placenta partially or completely covers the cervical opening, can cause significant bleeding and is typically managed with a cesarean delivery to prevent further bleeding and ensure the safety of the mother and baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Implementing seizure precautions is not necessary based on these lab results. Seizure precautions are typically implemented for patients with a known seizure disorder or those who are at risk for seizures, such as patients with severe preeclampsia or eclampsia, neither of which can be diagnosed based on these lab results.
Choice B rationale
Checking deep tendon reflexes every hour is not indicated based on these lab results. This action is typically taken for patients with altered neurological status or those receiving certain medications that can affect muscle tone.
Choice C rationale
Reviewing the daily logs of the patient is a good practice in general to monitor the patient’s progress and response to treatment. However, it is not a specific action that should be taken based on these lab results.
Choice D rationale
Obtaining a prescription for methyldopa is not indicated based on these lab results.
Methyldopa is a medication used to treat high blood pressure, and there is no indication from these lab results that the patient has high blood pressure.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Variable decelerations are not related to fetal head compression. Fetal head compression typically results in early decelerations, not variable ones.
Choice B rationale
Variable decelerations are indeed due to umbilical cord compression. They are quick decreases in fetal heart rate that vary with uterine contractions. This can be a sign that the baby’s blood flow is reduced if variable decelerations happen over and over.
Choice C rationale
Uteroplacental insufficiency typically results in late decelerations, not variable ones. Late decelerations are a sign of fetal hypoxia and are associated with uteroplacental insufficiency.
Choice D rationale
While certain medications can affect the fetal heart rate, variable decelerations are not typically a result of the administration of narcotic analgesics.
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