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.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Inserting an IV catheter is a standard procedure in many hospital admissions and can be necessary for administering medications and fluids. However, it is not the immediate priority in the case of placenta previa. Placenta previa is a condition where the placenta covers the cervix, and the main risk associated with it is bleeding.

Choice B reason:
Monitoring vaginal bleeding is the priority nursing action for a client with placenta previa. This condition can lead to significant bleeding, which can be life-threatening for both the mother and the fetus. The nurse must assess the amount, color, and duration of any bleeding to make timely decisions regarding the need for further medical intervention or potential delivery if the bleeding is severe.

Choice C reason:
Applying an external fetal monitor is important to assess the fetus's well-being, especially if there is vaginal bleeding or other complications. However, it is not the first action to take. The immediate concern with placenta previa is the risk of hemorrhage, which can compromise the oxygen supply to the fetus, making monitoring maternal bleeding a higher priority.

Choice D reason:
Administering glucocorticoids may be indicated to accelerate fetal lung maturity if preterm delivery is anticipated. While this is an important consideration in the management of placenta previa, especially if there is a risk of preterm birth, it is not the first line of action. The initial focus should be on assessing and controlling any bleeding to stabilize the mother's condition.

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Correct Answer is B

Explanation

Choice A reason:
Magnesium sulfate is used in the management of severe preeclampsia primarily for seizure prophylaxis. One of the key side effects of magnesium sulfate is its impact on neuromuscular transmission, leading to diminished deep-tendon reflexes as serum magnesium levels rise. The therapeutic range for anticonvulsant prophylaxis is typically between 5-8 mg/dL. Reflexes may begin to diminish when serum levels reach 8-12 mg/dL, indicating potential magnesium toxicity. Therefore, diminished reflexes are a warning sign to reassess the infusion rate and possibly reduce or discontinue the medication.

Choice B reason:
A respiratory rate of 16 breaths per minute falls within the normal adult range and suggests that the client's respiratory system is not being adversely affected by the magnesium sulfate infusion. Respiratory rate is a critical parameter to monitor during magnesium sulfate therapy, as respiratory depression is a serious side effect of magnesium toxicity. Maintaining a normal respiratory rate indicates that it is safe to continue the infusion at the current rate.

Choice C reason:
While a urine output of 50 mL/hr is on the lower end of the normal range, it is still considered adequate for most adults. In the setting of magnesium sulfate therapy for severe preeclampsia, maintaining adequate urine output is essential for ensuring that the kidneys can excrete the magnesium to prevent accumulation and toxicity. If urine output decreases significantly, it may necessitate reevaluation of the infusion rate or additional interventions to support renal function.

Choice D reason:
A heart rate of 56 beats per minute is slightly bradycardic but may not be clinically significant if the client is asymptomatic. However, magnesium has a direct effect on cardiac function, and high levels can lead to bradycardia and other cardiac conduction abnormalities. It is important to monitor the client's heart rate and rhythm during magnesium sulfate therapy to detect any early signs of cardiac involvement due to magnesium toxicity.

A. Amniotic fluid volume B. Fetal breathing C. Fetal motion D. Fetal neck translucency E. Fetal gender

Correct Answer is ["A","B","C"]

Explanation

Choice A reason:
Amniotic fluid volume is one of the components evaluated during a biophysical profile. It is assessed because adequate amniotic fluid is essential for fetal development and can indicate the health of the pregnancy. A normal amniotic fluid volume suggests that the fetus's kidneys are functioning well and that there is no leakage or rupture of membrane.

Choice B reason:
Fetal breathing is another key component of the biophysical profile. The presence of fetal breathing movements is a positive sign, indicating that the central nervous system is functioning and the fetus is getting enough oxygen.

Choice C reason:
Fetal motion is also assessed during a biophysical profile. Multiple discrete body or limb movements within a certain time frame are considered normal and indicate good fetal health and activity levels.

Choice D reason:
Fetal neck translucency is not evaluated in a biophysical profile. This measurement is typically assessed during the first trimester as part of screening for chromosomal abnormalities, not as a part of the biophysical profile.

Choice E reason:
Fetal gender is not a component of the biophysical profile. The biophysical profile focuses on the well-being of the fetus rather than determining its sex.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Correct Answer is B

Explanation

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. The nurse should include the following:

Correct Answer is ["A","B","C"]

Explanation

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