A client at 28 weeks of gestation presents with bleeding from the vagina.
Which assessment finding should the nurse prioritize?
Regular uterine contractions occurring every 15 minutes
Low back pain and pelvic pressure
Change in vaginal discharge
Rupture of membranes
The Correct Answer is A
Regular uterine contractions occurring every 15 minutes.
This finding suggests that the client may have placental abruption, which is a serious complication that requires immediate medical attention. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause heavy bleeding, pain, and fetal distress.
Choice B is wrong because low back pain and pelvic pressure are common symptoms of preterm labor, which is not as urgent as placental abruption.
Choice C is wrong because a change in vaginal discharge is not a specific sign of any complication and may be normal in pregnancy.
Choice D is wrong because rupture of membranes is not a priority finding in this case, unless it is associated with infection or cord prolapse.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Drinking enough water can help prevent dehydration, which can trigger preterm labor contractions.Dehydration can also cause low amniotic fluid levels, which can affect fetal growth and development.
Choice A is wrong because avoiding sexual intercourse until term is not necessary for most women at risk for preterm labor.Sexual activity does not cause preterm labor unless there are other complications, such as placenta previa or cervical insufficiency.
Choice C is wrong because lying down when feeling contractions may not stop preterm labor.If a woman has regular contractions that cause cervical change, she should seek medical attention as soon as possible.Lying down may also reduce blood flow to the uterus and placenta, which can affect fetal oxygenation.
Choice D is wrong because taking aspirin for pelvic pain is not recommended for pregnant women.Aspirin can increase the risk of bleeding and affect fetal blood circulation.
Pelvic pain may be a sign of preterm labor or other complications, so it should be evaluated by a health care provider
Correct Answer is C
Explanation
White blood cell count 25,000/mm3.
This indicates a potential complication of necrotizing enterocolitis (NEC), which is the death of intestinal tissue in premature or sick newborns.A high white blood cell count can be a sign of infection or inflammation in the bowel, which are common features of NEC.
Choice A is wrong because hematocrit 45% is within the normal range for newborns.
Hematocrit measures the percentage of red blood cells in the blood.
A low hematocrit can indicate blood loss or anemia, which can be complications of NEC, but a normal hematocrit does not rule out NEC.
Choice B is wrong because platelets 150,000/mm3 is also within the normal range for newborns.
Platelets are cells that help the blood clot.A low platelet count can indicate a consumption coagulopathy, which is a bleeding disorder that can occur in severe cases of NEC.
However, a normal platelet count does not exclude NEC.
Choice D is wrong because blood glucose 80 mg/dL is also within the normal range for newborns.
Blood glucose measures the amount of sugar in the blood.
A low blood glucose can indicate hypoglycemia, which can be caused by sepsis or other conditions that mimic NEC, but a normal blood glucose does not eliminate NEC.
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