NCLEX-RN · Question #427
The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be admitted to the hospital for a cesarean section. The client is now at 36 weeks' gestation and…
The correct answer is B. Determine the status of the fetus by fetal heart tones. (A) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (B) Determining the physiological status of the fetus would constitute the highest priority in evaluating and maintaining fetal life. (C)…
Question
The nurse is notified that a 27-year-old primigravida diagnosed with complete placenta previa is to be admitted to the hospital for a cesarean section. The client is now at 36 weeks' gestation and ispresently having bright red bleeding of moderate amount. On admission, the nursing intervention that the nurse should give the highest priority to is:
Options
- AShave the client's abdomen and arrange her lab work
- BDetermine the status of the fetus by fetal heart tones
- CStart an IV infusion in the client's arm
- DInsert an indwelling catheter into her bladder
How the community answered
(37 responses)- A5% (2)
- B73% (27)
- C5% (2)
- D16% (6)
Explanation
(A) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (B) Determining the physiological status of the fetus would constitute the highest priority in evaluating and maintaining fetal life. (C) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium. (D) These nursing actions are necessary prior to the cesarean section, but not immediately necessary to maintain physiological equilibrium.
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