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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
While burping can be a sign that a baby is feeding, it is not a reliable indicator of whether the baby is getting enough breast milk. Burping is a way to release air that babies swallow during feeding, which can help prevent discomfort and gas. However, it does not correlate directly with the amount of milk intake.
Choice B reason:
The number of wet diapers is a direct indicator of a baby's hydration status and, by extension, how much breast milk they are receiving. A newborn who is getting enough milk will typically have 6 to 8 wet diapers per day after the first few days of life. This shows that the baby is well-hydrated and is receiving sufficient milk.
Choice C reason:
Sleep patterns in newborns can vary widely, and sleeping for at least 6 hours between feedings is not typical for a 2-day-old baby. Newborns usually need to feed every 2 to 3 hours, and long stretches of sleep without feeding may indicate that the baby is not getting enough milk and does not have the energy to wake and feed.
Choice D reason:
A wake cycle of 30 to 60 minutes after feeding can be normal for some babies, but it is not a measure of whether they are getting enough milk. The wake cycle can be influenced by many factors, including the baby's overall health, comfort, and environment.
Correct Answer is D
Explanation
Choice a reason:
While ultrasound can be used for estimating fetal age, at 36 weeks of gestation, this is not the primary reason for performing an ultrasound before an amniocentesis. Fetal age is usually estimated earlier in the pregnancy to help with dating the pregnancy and determining the due date.
Choice b reason:
Determining if there is more than one fetus is typically established earlier in the pregnancy. By 36 weeks, the presence of multiples would already be known, so this would not be the primary reason for an ultrasound before an amniocentesis at this stage.
Choice c reason:
An ultrasound can be used as a screening tool for spina bifida, but it is not the main reason for an ultrasound before an amniocentesis at 36 weeks. Screening for spina bifida and other anomalies is usually done during the second trimester.
Choice d reason:
The primary reason for an ultrasound before an amniocentesis is to identify the location of the placenta and fetus. This information is crucial to ensure the safety of both the mother and the fetus during the procedure by avoiding injury to the placenta and ensuring the amniotic needle is inserted in a safe location.
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