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 A
Explanation
The nurse's first action should be to massage the woman's fundus. A completely saturated perineal pad within 15 minutes after giving birth indicates excessive bleeding, which is also known as postpartum hemorrhage (PPH). Massaging the uterus (fundus) can help it to contract, reduce bleeding, and prevent further blood loss. Once the fundus has been massaged, the nurse should assess the woman's vital signs and continue to monitor her for signs of continued bleeding. If bleeding persists despite massage, the nurse should begin an intravenous (IV) infusion of Ringer's lactate solution and call the woman's primary healthcare provider.
Correct Answer is B
Explanation
Placenta previa is a condition where the placenta implants low in the uterus, covering part or all of the cervix. This can cause bleeding and can be dangerous for both the mother and the baby. In cases of placenta previa, a cesarean delivery is necessary to avoid complications. Therefore, it is not safe for the patient to deliver vaginally.
Betamethasone is indicated in delivery anticipated before 34 weeks gestation. Vaginal exams may cause more bleeding in the event of placenta previa.
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