Nokea
The nurse is assessing a client with suspected placenta previa. Which finding supports this diagnosis?
- A. Painful, bright red bleeding.
- B. Painless, bright red bleeding.
- C. Hard, rigid abdomen.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red bleeding. Placenta previa is characterized by painless vaginal bleeding due to the placenta covering the cervical os. Bright red blood indicates fresh bleeding from the lower uterus. This finding supports the diagnosis as it aligns with the classic presentation of placenta previa.
A: Painful, bright red bleeding is not characteristic of placenta previa, as the bleeding is usually painless.
C: A hard, rigid abdomen is more indicative of a uterine rupture or abruption, not placenta previa.
D: Decreased fetal movements are not directly associated with placenta previa; this finding may suggest fetal distress but is not specific to this condition.
You may also like to solve these questions
A client at 38 weeks' gestation is admitted for decreased fetal movement. What diagnostic test should the nurse anticipate?
- A. Amniocentesis.
- B. Biophysical profile (BPP).
- C. Contraction stress test.
- D. Maternal serum alpha-fetoprotein (MSAFP).
Correct Answer: B
Rationale: The correct answer is B: Biophysical profile (BPP). At 38 weeks' gestation with decreased fetal movement, BPP is used to assess fetal well-being by evaluating fetal heart rate, fetal movements, fetal tone, amniotic fluid volume, and sometimes placental function. It provides immediate information on fetal status and is non-invasive. Amniocentesis (A) is not indicated for decreased fetal movement. Contraction stress test (C) is contraindicated due to the risk of inducing contractions in a term pregnancy. Maternal serum alpha-fetoprotein (D) is a screening test for neural tube defects and is not relevant in this situation.
The nurse is preparing a client for a biophysical profile (BPP). What does this test evaluate?
- A. Maternal blood flow to the placenta.
- B. Fetal genetic abnormalities.
- C. Fetal well-being, including movements and amniotic fluid.
- D. Cervical dilation and effacement.
Correct Answer: C
Rationale: The correct answer is C: Fetal well-being, including movements and amniotic fluid. A Biophysical Profile evaluates the fetus' health by assessing factors like fetal movements, muscle tone, breathing movements, amniotic fluid volume, and fetal heart rate patterns. This test provides valuable information about the fetus' well-being and helps in determining the need for interventions or further monitoring.
Explanation of why the other choices are incorrect:
A: Maternal blood flow to the placenta is not evaluated by a Biophysical Profile.
B: Fetal genetic abnormalities are not assessed through a BPP; it focuses on the fetus' current well-being.
D: Cervical dilation and effacement are related to labor progress and not part of a BPP, which focuses on fetal well-being.
A preterm neonate develops physiologic jaundice and phototherapy is ordered. The nurse understands that this therapy:
- A. Activates the liver to dispose the bilirubin
- B. Breaks down the unconjugated bilirubin in the skin to conjugated form permitting excretion
- C. Activates Vit. K to facilitate excretion of the bilirubin
- D. Dissolves the bilirubin and allows it to be excreted from the skin
Correct Answer: B
Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.
The nurse is monitoring a client in labor and suspects hypertonic uterine contractions. What is the priority nursing action?
- A. Provide pain relief measures.
- B. Prepare the client for an amniotomy.
- C. Promote ambulation every 30 minutes.
- D. Monitor the oxytocin infusion closely.
Correct Answer: A
Rationale: The correct answer is A: Provide pain relief measures. In hypertonic uterine contractions, the uterus contracts too frequently and intensely, leading to increased pain and potential fetal distress. Providing pain relief helps alleviate discomfort for the client and may reduce the risk of fetal distress. Other choices are incorrect because: B) Amniotomy may not be necessary and could potentially worsen the situation. C) Ambulation may not be safe or effective during hypertonic contractions. D) Monitoring the oxytocin infusion closely is important but not the priority in managing hypertonic contractions.
The nurse is teaching the postpartum client about newborn transitional stool. Which should the nurse include in the teaching session? SATA
- A. They have greenish brown color
- B. They are looser consistency
- C. They are seedy with sweet sour smell
- D. They have tar like consistency
Correct Answer: A
Rationale: The correct answer is A because transitional stools in newborns typically have a greenish-brown color due to the presence of meconium and the changing composition of the stool as the baby starts digesting breastmilk or formula.
Rationale:
1. A: Greenish-brown color is characteristic of transitional stools as meconium is being passed out.
Incorrect answers:
2. B: Transitional stools are not necessarily looser in consistency.
3. C: Transitional stools are not typically described as seedy with a sweet-sour smell.
4. D: Tar-like consistency is more indicative of meconium, not transitional stools.