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 B
Explanation
Choice A rationale
Vaginal discharge is common during pregnancy due to the increased production of estrogen and greater blood flow to the pelvic area. It is not typically a sign of preeclampsia.
Choice B rationale
Elevated blood pressure is a primary symptom of preeclampsia. If a pregnant client has high blood pressure, it should indicate to the nurse that the client requires further evaluation for this disorder.
Choice C rationale
Joint pain is not typically a symptom of preeclampsia. It could be related to other conditions or simply a result of the physical changes of pregnancy.
Choice D rationale
Increased urine output is not typically associated with preeclampsia. In fact, decreased urine output could potentially be a sign of kidney problems related to preeclampsia.
Correct Answer is A
Explanation
Choice A rationale
The maternal serum alpha-fetoprotein (MSAFP) test is a screening test that measures the level of alpha-fetoprotein in the mother’s blood during pregnancy. It is used to assess the likelihood of certain birth defects, including neural tube defects such as spina bifida.
Choice B rationale
The MSAFP test does not assess fetal lung maturity. Other tests, such as amniocentesis, can be used to assess this.
Choice C rationale
The MSAFP test does not identify Rh incompatibility between the mother and fetus. Rh incompatibility is typically determined through blood typing and antibody screening.
Choice D rationale
While the MSAFP test can provide valuable information about the health of the fetus, it does not assess various markers of fetal well-being. It is specifically used to screen for certain birth defects.
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