“A nurse is caring for a patient who is at 32 weeks of gestation and has complete placenta previa. Which of the following assessment findings requires immediate follow-up?”
“Vaginal bleeding.”.
“Fetal heart rate of 174 bpm.”.
“Fundal height of 33 cm.”.
“Abdomen soft on palpation and without tenderness.”.
The Correct Answer is A
Choice A rationale
Placenta previa is a condition where the placenta partially or completely covers the cervix. Vaginal bleeding, often without pain, is a key symptom and requires immediate medical attention.
Choice B rationale
While a fetal heart rate of 174 bpm is slightly above the normal range (110-160 bpm), it is not the most critical finding in a patient with complete placenta previa.
Choice C rationale
A fundal height of 33 cm at 32 weeks of gestation is within the expected range and does not require immediate follow-up.
Choice D rationale
An abdomen that is soft and non-tender is a normal finding and does not require immediate follow-up.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Epigastric discomfort is not typically associated with pyelonephritis. It may be a symptom of other conditions such as gastrointestinal issues or preeclampsia.
Choice B rationale
Abdominal cramping is not a typical manifestation of pyelonephritis. It could be a symptom of various other conditions, including gastrointestinal disorders or gynecological issues.
Choice C rationale
A temperature of 37.2°C (99.8°F) is within the normal range and is not indicative of pyelonephritis. Pyelonephritis, an infection of the kidneys, is typically associated with a high fever.
Choice D rationale
Flank pain is a common manifestation of pyelonephritis. This is because the kidneys, which are affected in pyelonephritis, are located in the flank area.
Correct Answer is B, A, C, D, E
Explanation
Step 1 is to apply a warm cloth to the newborn’s heel for 5 to 10 minutes. Warming the heel improves blood flow to the area, making it easier to obtain a blood sample.
Step 2 is to clean the area with an antiseptic. This is to prevent infection.
Step 3 is to puncture the outer aspect of the newborn’s heel. The outer aspect of the heel is less sensitive and less likely to be injured by the lancet.
Step 4 is to collect the blood specimen. After the heel has been punctured, blood will start to flow out and can be collected.
Step 5 is to apply pressure to the site with a dry gauze pad. This is to stop the bleeding after the blood sample has been collected.
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