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:
Checking basal body temperature 1 hour following intercourse is not recommended as a method to determine ovulation. Intercourse and physical activity can increase body temperature, which may lead to inaccurate readings. Basal body temperature should be measured after a period of rest, not after physical activity.

Choice B reason:
The basal body temperature method involves measuring the body's at-rest temperature to identify slight changes that occur around the time of ovulation. It is most accurate when taken every morning before getting out of bed, after at least 3 hours of uninterrupted sleep, and before any physical activity, including eating or drinking. A slight increase in basal body temperature typically occurs after ovulation and remains elevated until the next menstrual period. This method requires consistency and precise timing to be effective.

Choice C reason:
Measuring basal body temperature before going to bed every night is not an effective way to track ovulation. The body's temperature fluctuates throughout the day due to various factors, including activity levels, meals, and external temperatures. Therefore, nighttime measurements would not provide the consistent, resting temperature needed to accurately detect ovulation.

Choice D reason:
While it is true that ovulation typically occurs around the middle of the menstrual cycle, which for many women is between days 13 to 17, limiting temperature checks to these days only may miss the initial rise in temperature that indicates ovulation. Ovulation can vary from cycle to cycle, and it is important to measure basal body temperature daily to detect the pattern over time.

A. Slightly below the umbilicus. B. 3 cm above the umbilicus. C. Slightly above the umbilicus. D. 3 cm below the umbilicus.

Correct Answer is D

Explanation

Choice a reason:
Slightly below the umbilicus is not the expected location for the fundus at 22 weeks of gestation. Typically, the fundus is located at the level of the umbilicus at 20 weeks and rises about 1 cm above the umbilicus each week thereafter.

Choice b reason:
3 cm above the umbilicus would be more consistent with a gestational age of approximately 23 weeks, as the fundus rises approximately 1 cm per week after reaching the level of the umbilicus at 20 weeks.

Choice c reason:
Slightly above the umbilicus would be an expected finding slightly later in gestation, around 21 weeks, as the fundus height increases about 1 cm per week after reaching the umbilicus at 20 weeks.

Choice d reason:
3 cm below the umbilicus is the expected location for the fundus at 22 weeks of gestation. Fundal height measurements typically correspond with the number of weeks of gestation, plus or minus 2 cm. Therefore, at 22 weeks, the fundus would be expected to be slightly below the umbilicus, as it would have just recently risen to the level of the umbilicus at 20 weeks.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is instructing a female client on how to check her basal body temperature to determine if she is ovulating. The nurse should instruct the client to check her temperature at which of the following times?

Correct Answer is B

Explanation

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is D

Explanation

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