A nurse is reinforcing teaching with a client at her first prenatal visit about expected changes during gestation. (Arrange the steps in order, placing them in the selected order of occurrence from earliest to latest in gestation. Use all the steps.)
Breast tenderness
Nausea and vomiting
Quickening
Goodell's sign
Striae gravidarum
Lightening
Correct Answer : A,B,C,D,E,F
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
G (Gravida) — Total number of pregnancies, including the current one.
Elective abortion at 9 weeks
Birth of twins at 36 weeks
Spontaneous abortion at 15 weeks
Current pregnancy at 28 weeks So, G = 4.
T (Term births) — Number of pregnancies carried to 37 weeks or beyond.
-
- She hasn't had any pregnancies reach full term. So, T = 0.
P (Preterm births) — Number of pregnancies delivered between 20 and 36 weeks.
-
- Twins born at 36 weeks. So, P = 1.
A (Abortions) — Number of pregnancies ending before 20 weeks (spontaneous or elective).
-
- Elective abortion at 9 weeks
- Spontaneous abortion at 15 weeks So, A = 2.
L (Living children) — Number of living children.
-
- The twins are living children. So, L = 2.
Putting it all together, her GTPAL notation is G4 T0 P1 A2 L2.
Correct Answer is B
Explanation
b. Apply an external fetal monitor.
The nurse should apply an external fetal monitor to assess the fetal heart rate and activity, as well as the presence and intensity of contractions. Placenta previa is a condition where the placenta covers part or all of the cervical opening, which can cause painless, bright red bleeding in the third trimester. Placenta previa can compromise fetal oxygenation and perfusion, and can also trigger preterm labor. Therefore, the nurse should monitor the fetal well- being and readiness for delivery.
The other actions are not appropriate and may cause harm to the client or the fetus.
a. The nurse should not perform a rectal exam, as this can cause trauma or infection to the rectum or the placenta, and increase the risk of bleeding or rupture.
c. The nurse should not complete a vaginal exam, as this can dislodge or damage the placenta, and cause severe
hemorrhage or shock.
d. The nurse should not apply ice to the perineal area, as this can cause vasoconstriction and reduce blood flow to the placenta and the fetus, and worsen their condition.
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