A patient arrives at OB triage with a complaint of vaginal bleeding. The nurse would prioritize all of the following questions during the assessment except:
How many weeks are you?
Are you experiencing any pain?"
When was your last ultrasound?
"Do you plan to have a vaginal or cesarean delivery?"
The Correct Answer is D
The question that the nurse would prioritize the least during the assessment is "Do you plan to have a vaginal or cesarean delivery?" This is because the priority at this point is to determine the urgency of the situation and assess the patient's current condition. The patient's delivery plan can be addressed later after the initial assessment is completed and the patient's stability has been established.
The other questions are all important in determining the cause and severity of the bleeding and the appropriate course of action. The question about the number of weeks is important to determine the gestational age and potential causes of bleeding, as some causes are more common in certain stages of pregnancy. The question about pain can help to determine the possible causes of bleeding and the patient's comfort level. The question about the last ultrasound is important to determine the location of the placenta and whether there are any abnormalities or potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
After a forceps-assisted birth, the infant should be assessed for signs of trauma or injury, such as bruising, facial nerve injury, or skull fractures. This assessment should be done immediately after the birth to ensure prompt recognition and management of any issues.
Option A is incorrect because measuring the circumference of the infant's head can be done after the assessment for trauma has been completed and any issues have been addressed.
Option B is incorrect because applying a cold pack to the infant's scalp is not a standard nursing intervention after a forceps-assisted birth.
Option D is incorrect because prophylactic antibiotics are not routinely administered to infants after a forceps-assisted birth unless there is a specific indication, such as suspected infection.
Correct Answer is B
Explanation
Caput succedaneum is a common condition in newborns that causes swelling of the soft tissues of the scalp. It is usually caused by pressure on the baby's head during delivery and can be seen in both vaginal and instrumental births, such as vacuum-assisted deliveries. It generally crosses the suture lines, unlike a cephalohematoma.
Caput succedaneum is not a serious condition and generally resolves on its own within a few days without any treatment. However, the nurse should continue to monitor the newborn for signs of jaundice, which can occur due to the breakdown of red blood cells in the swelling.
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