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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice a reason:
Washing the perineal area using a squeeze bottle of warm water after each voiding is a recommended practice to reduce the risk of infection. This method gently cleanses without causing irritation and ensures that any bacteria are washed away, which is particularly important after a vaginal delivery when the perineal tissue may be more susceptible to infection.
Choice b reason:
Applying ice packs to the perineal area several times daily can help reduce swelling and provide pain relief, but it is not directly related to reducing the risk of infection. Ice packs should be used as part of pain management and swelling reduction rather than for hygiene purposes.
Choice c reason:
Blotting the perineal area dry after cleansing is important to maintain the integrity of the skin and prevent moisture buildup, which can create an environment conducive to bacterial growth. Patting the area dry gently can help prevent irritation and reduce the risk of infection.
Choice d reason:
Cleaning the perineal area from front to back is a critical practice to prevent the spread of bacteria from the anal area to the vagina and urethra, which can cause urinary tract infections. This technique is especially important postpartum when the perineal area is healing.
Choice e reason:
Performing hand hygiene before and after voiding is a fundamental practice to prevent the introduction of pathogens to the perineal area and reduce the risk of infection. Proper handwashing can significantly decrease the likelihood of perineal infections by ensuring that the hands are clean when they come into contact with sensitive areas.
Correct Answer is C
Explanation
Choice a Reason: Encourage the client to move to the left lateral position
Moving to the left lateral position is often recommended to improve circulation and prevent compression of the vena cava by the uterus in a pregnant client. However, in the case of a boggy fundus postpartum, this position is not the primary action to be taken.
Choice b Reason: Ask the client to rate her pain
While assessing pain is important in the postpartum period, it is not the immediate action required for a boggy fundus. A boggy fundus indicates that the uterus is not contracting properly, which can lead to excessive bleeding.
Choice c Reason: Assist the client to the bathroom to void
A boggy fundus that is displaced to the right often indicates a full bladder, which can prevent the uterus from contracting effectively. Assisting the client to the bathroom to void can help the uterus contract and reduce the risk of hemorrhage.
Choice d Reason: Encourage the client to perform Kegel exercises
Kegel exercises are beneficial for strengthening the pelvic floor muscles after childbirth. However, they are not the immediate action to take for a boggy fundus postpartum
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