“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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Providing a stimulating environment is not recommended for infants with neonatal abstinence syndrome (NAS). These infants often have a heightened response to stimuli, and a calm, quiet environment is usually more beneficial.
Choice B rationale
While it is important to monitor the infant’s overall health, there is no specific need to monitor blood glucose level every hour in infants with NAS unless there is a separate medical indication.
Choice C rationale
Initiating seizure precautions is an appropriate action for a nurse caring for an infant with signs of NAS5. Infants with NAS are at risk for seizures, so nurses should be prepared to manage this potential complication.
Choice D rationale
Placing the infant on his back with legs extended is not recommended. Infants with NAS often have increased muscle tone and may be uncomfortable in this position.
Correct Answer is A
Explanation
Choice A rationale
In the case of intrauterine fetal demise at 36 weeks of gestation, the most common treatment option is induction of labor.
Choice B rationale
An immediate cesarean birth is typically not the first choice of treatment for intrauterine fetal demise unless there are other complications.
Choice C rationale
Methotrexate is used to treat ectopic pregnancies, not intrauterine fetal demise.
Choice D rationale
Dilation with suction curettage is typically used for early pregnancy loss, not late-term intrauterine fetal demise.
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