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
Rigid abdomen
Increased fetal movement
Persistent uterine contractions
The Correct Answer is A
Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. The bleeding is typically painless and bright red in color. This is an important finding that should be assessed and monitored closely.
A rigid abdomen is not a characteristic finding of placenta previa. It could be a sign of another condition such as placental abruption or uterine rupture, which are separate complications. Fetal movement is not directly related to placenta previa. It is a normal finding and can vary depending on the gestational age and individual fetal patterns.
Placenta previa is not typically associated with persistent uterine contractions. However, it is important to monitor for any signs of preterm labor or other complications that could cause uterine contractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
B.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
C.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
D.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
Correct Answer is C
Explanation
When a charge nurse observes the smell of alcohol on a nurse's breath, it raises concerns about their ability to provide safe and competent care to clients. Patient safety is of utmost importance, and the charge nurse must take immediate action to address the situation.
Removing the nurse from the client care area ensures that the nurse is not involved in direct patient care while their ability to provide safe care is in question. This step helps mitigate potential risks to patient safety.
B and D- After removing the nurse from the client care area, further actions can be taken, such as documenting the objective findings about the situation and informing the supervisor. However, the immediate priority is to ensure patient safety by removing the nurse from the care area.
A- Assigning clients to the remaining staff can be done once the situation has been addressed and a suitable replacement for the nurse has been arranged.
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