A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?

Bright red vaginal bleeding

Persistent uterine contractions

Increased fetal movement

Rigid abdomen

Answer and Explanation

The Correct Answer is A

A.   Correct. Placenta previa is a condition where the placenta covers part or all of the cervix.
Bright red vaginal bleeding, especially painless bleeding, is a hallmark sign of placenta previa.
B.   Incorrect. Persistent uterine contractions are not a typical finding in placenta previa and could indicate preterm labor or other issues.
C.   Incorrect. Increased fetal movement is not a characteristic sign of placenta previa.
D.   Incorrect. A rigid abdomen is not associated with placenta previa; it could be a sign of other conditions such as placental abruption.

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Correct Answer is B

Explanation

A.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.

B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.

C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.

D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.

A. Measure the client's abdominal girth daily. B. Restrict the client's sodium intake to 3 g per day. C. Keep the client's daily protein intake below 0.8 g/kg. D. Position the client supine with legs elevated.

Correct Answer is A

Explanation

A. Correct. Measuring abdominal girth daily is important to monitor for changes in ascites and fluid retention.
B. Restricting sodium intake is important for clients with ascites to manage fluid retention, but a specific limit of 3 g per day is not universally applicable.
C. Protein intake should not be significantly restricted for clients with ascites; protein is essential for maintaining adequate serum albumin levels.
D. Positioning the client supine with legs elevated might be uncomfortable and not directly related to managing ascites.

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