Author Question: A client at 32 weeks' gestation is admitted with painless vaginal bleeding. Placenta previa has been ... (Read 61 times)

folubunmi · **on:** Jun 27, 2018

A client at 32 weeks' gestation is admitted with painless vaginal bleeding. Placenta previa has been confirmed by ultrasound.

What should be included in the nursing plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. No vaginal exams
2. Encouraging activity
3. No intravenous access until labor begins
4. Evaluating fetal heart rate with an external monitor
5. Monitoring blood loss, pain, and uterine contractility

Question 2

Which nursing diagnoses would the nurse apply to a newborn exposed to HIV/AIDS? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

1. Altered Nutrition: More than Body Requirements
2. Risk for Impaired Skin Integrity
3. Risk for Infection
4. Impaired Physical Mobility
5. Sleep Pattern Disturbance

Moriaki · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

1, 4, 5
Explanation: 1. Expectant management of placenta previa is made by localizing the placenta via tests that require no vaginal examination.
4. Expectant management of placenta previa, when the client is at less than 37 weeks' gestation, includes evaluating FHR with an external monitor.
5. Expectant management of placenta previa, when the client is at less than 37 weeks' gestation, includes monitoring blood loss, pain, and uterine contractility.

Answer to Question 2

2,3,4
Rationale 1: The correct diagnosis would be Less than Body Requirements related to formula intolerance and inadequate intake.
Rationale 2: Risk of impaired skin integrity is related to chronic diarrhea.
Rationale 3: Risk for infection is related to perinatal exposure and immunoregulation suppression secondary to HIV/AIDS.
Rationale 4: Impaired physical mobility is related to decreased neuromuscular development.
Rationale 5: This diagnosis is pertinent to the newborn who is drug-exposed, related to CNS excitation secondary to drug withdrawal.