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.
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 D
Explanation
Choice A reason:
Administering oxygen using a non-rebreather mask is a subsequent step if initial measures do not improve fetal heart rate decelerations. It can help increase the amount of oxygen available to the fetus. Oxygen administration is a supportive measure that can be used if there are signs of fetal distress. In the scenario described, where the fetal heart rate slows after the start of a contraction with the lowest rate occurring after the peak, it suggests late decelerations, which are often associated with uteroplacental insufficiency. Administering oxygen can help increase the fetal oxygen reserve and is a common intervention during labor when there are concerns about fetal well-being.
Choice B reason:
Increasing the rate of maintenance IV infusion is typically considered when there is a concern for maternal hypotension or dehydration, which may not be the immediate cause of the observed fetal heart rate pattern. Increasing the rate of an IV infusion can help improve maternal hydration and blood pressure, which in turn can enhance placental perfusion. However, this intervention is more indirect and may not provide the immediate response needed to address fetal heart rate decelerations. It is typically considered after more direct interventions, such as repositioning the mother, have been attempted.
Choice C reason:
Elevating the client's legs can help improve venous return to the heart, potentially increasing maternal cardiac output and blood flow to the placenta. While this can be beneficial, it is not the primary intervention for late decelerations. Repositioning the mother to improve uteroplacental circulation is generally the first step.
Choice D reason:
Placing the client in the lateral position is often the first action taken when late decelerations are observed. This position helps improve uteroplacental blood flow and can quickly address potential issues related to fetal oxygenation. This position helps to relieve pressure on the inferior vena cava and aorta, which can be compressed by the gravid uterus, especially in the supine position. Relieving this pressure helps to improve uteroplacental circulation and can quickly address the cause of late decelerations, which is often related to compromised blood flow to the placenta.
Correct Answer is A
Explanation
Choice A Reason:
Using a cotton-tipped swab to clean a newborn's nares can be dangerous. It can push debris further into the nose, cause mucosal damage, bleeding, or even introduce germs. Instead, the nurse should advise the mother to use a bulb syringe for gentle suction if necessary.
Choice B Reason:
Leaving the yellow exudate on the circumcision site is actually recommended. This exudate is part of the normal healing process and does not need to be removed. It acts as a natural barrier to infection and will clear up as the circumcision heals.
Choice C Reason:
Cleaning the umbilical cord with tap water is generally considered safe and can help keep the area clean. However, the nurse should ensure that the mother dries the area thoroughly afterward to prevent moisture from promoting bacterial growth.
Choice D Reason:
Cleaning the newborn's eyes from the inner canthus outwards is the correct technique. It prevents contamination from the outer part of the eye to the inner part and helps to clear any discharge or debris effectively.
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