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 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
Correct Answer is C
Explanation
Choice A reason: Blunt force trauma, such as from a car accident or a fall, can indeed cause placental abruption, but it is not the most common risk factor. Trauma can lead to the placenta detaching from the uterine wall, but such events are less frequent compared to other risk factors.
Choice B reason: Cigarette smoking is associated with a variety of pregnancy complications, including placental abruption. However, while smoking does increase the risk, it is not considered the most common risk factor when compared to hypertension.
Choice C reason: Hypertension is the most common risk factor for placental abruption. High blood pressure can damage the blood vessels in the uterus, leading to the placenta detaching prematurely.
Choice D reason: Cocaine use during pregnancy can lead to placental abruption because it causes the blood vessels to constrict, which can reduce blood flow to the placenta and cause detachment. While it is a significant risk factor, it is less common than hypertension in the general population.
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