Which of the following is the priority nursing action for a client at 33 weeks of gestation with a diagnosis of placenta previa?

Insert an IV catheter.

Monitor vaginal bleeding.

Apply an external fetal monitor.

Administer glucocorticoids.

None

Answer and Explanation

The Correct Answer is C

Choice A rationale: Establishing IV access is necessary for potential fluid or blood replacement, but it is not the immediate priority over assessing the current physiological status of the fetus.

Choice B rationale: Monitoring the amount and color of vaginal bleeding is a vital assessment, but it does not provide direct information regarding the fetal response to the placental complication.

Choice C rationale: Assessing the fetal heart rate via external monitoring is the priority to ensure fetal well-being and detect distress, as the fetus is at high risk for hypoxia in placenta previa.

Choice D rationale: Glucocorticoids are administered to promote fetal lung maturity in anticipation of a preterm birth, but this intervention occurs after the initial assessment of fetal and maternal stability.

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Correct Answer is D

Explanation

Choice A reason:
A soft, edematous area on the scalp, often referred to as a cephalohematoma, is a common finding after vacuum-assisted deliveries. This is due to the suction applied during delivery and usually resolves without intervention. However, it should be monitored for any signs of increased swelling or jaundice as it can sometimes lead to hyperbilirubinemia.

Choice B reason:
The blue coloring of the hands and feet, known as acrocyanosis, is a normal finding in the first few days of life. It occurs due to the immature circulation in the newborn and typically resolves as the baby's circulation adapts to life outside the womb.

Choice C reason:
Facial edema can be present in newborns following a vacuum-assisted delivery due to the pressure applied during the procedure. It is usually transient and resolves within a few days. However, persistent or severe edema may warrant further evaluation.

Choice D reason:
Poor sucking is a significant finding that should be reported to the provider. Effective sucking is crucial for adequate nutrition and hydration in the newborn. Poor sucking can be a sign of neurological compromise or other issues that require immediate attention to ensure the baby can feed properly and thrive.

A. "It detects positive antibodies in the mother's blood." B. "It detects Rh-negative antibodies in the newborn's blood." C. "It determines if kernicterus will occur in the newborn." D. "It determines the presence of maternal antibodies in the newborn's blood."

Correct Answer is A

Explanation

Choice A reason: The indirect Coombs test is used to screen for antibodies in the mother's blood that could potentially cause hemolytic disease in the newborn if they are Rh-positive. A positive result indicates that the mother has developed antibodies that could cross the placenta and attack the red blood cells of an Rh-positive fetus.

Choice B reason: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. Instead, it is used to detect antibodies in the mother's blood. The direct Coombs test is used to detect antibodies that are already attached to the red blood cells of the newborn.

Choice C reason: The indirect Coombs test does not determine if kernicterus will occur in the newborn. Kernicterus is a form of brain damage that can result from very high levels of bilirubin in a baby's blood. It is not directly related to the presence of antibodies detected by the indirect Coombs test.

Choice D reason: The indirect Coombs test does not determine the presence of maternal antibodies in the newborn's blood. This is assessed by the direct Coombs test, which checks for antibodies bound to the surface of the newborn's red blood cells, indicating that the immune system is attacking them.

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Which of the following is the priority nursing action for a client at 33 weeks of gestation with a diagnosis of placenta previa?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

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