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 ["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.

A. Viability of the fetus B. The biparietal diameter C. Location of the placenta D. Fetal lung maturity

Correct Answer is C

Explanation

Choice a reason:
The viability of the fetus at 38 weeks of gestation is typically not the primary concern when heavy, red vaginal bleeding occurs without contractions. Fetal movements reported by the mother are a good sign of fetal well-being. However, the ultrasound in this scenario is more likely to be used to rule out placental issues that could cause bleeding, rather than to assess fetal viability.

Choice b reason:
The biparietal diameter (BPD) is a measurement taken during an ultrasound to assess fetal growth and development. While BPD is an important parameter, it is not typically the focus of an urgent ultrasound in the context of heavy vaginal bleeding late in pregnancy. The BPD is more relevant to growth assessments rather than acute bleeding episodes.

Choice c reason:
Locating the placenta is crucial in the case of heavy, red vaginal bleeding at 38 weeks of gestation. The bleeding could be indicative of placental abruption or placenta previa, both of which are serious conditions that require immediate medical attention. An ultrasound can quickly determine the location of the placenta and assess for these conditions.

Choice d reason:
Assessing fetal lung maturity is not typically the priority in an emergency situation involving heavy vaginal bleeding. While lung maturity is an important consideration for the timing of delivery, especially in preterm labor, the immediate concern in this scenario would be to identify the source of bleeding and ensure the safety of both the mother and fetus.

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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 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

Correct Answer is C

Explanation

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