A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

Increase in pulse and fetal rate reactivity.

Pain in lower quadrant and oliguria.

Mild discomfort and elevated blood pressure.

Sharp fundal pain and uterine tenderness.

Answer and Explanation

The Correct Answer is D

A. Increase in pulse and fetal rate reactivity: While changes in maternal pulse and fetal heart rate can indicate stress or early compromise, these findings alone do not specifically indicate acute maternal hemorrhage or uterine injury that requires immediate intervention.

B. Pain in lower quadrant and oliguria: These signs suggest possible urinary retention or renal compromise but are not the most urgent indicators of acute obstetric bleeding during labor.

C. Mild discomfort and elevated blood pressure: Mild discomfort and hypertension may reflect preeclampsia but do not specifically signal active hemorrhage requiring immediate reporting.

D. Sharp fundal pain and uterine tenderness: These findings are indicative of uterine rupture or abruption, both of which are obstetric emergencies. Profuse vaginal bleeding with uterine tenderness requires immediate notification of the healthcare provider to prevent maternal and fetal morbidity or

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Correct Answer is B

Explanation

A. Tell the client that the medication's side effects will most likely dissipate over time: While side effects may lessen with continued use, this response does not address the client’s intent to stop the medication safely.

B. Inform the client that gradual tapering must be used to discontinue the medication: Abrupt discontinuation of antidepressants can lead to withdrawal symptoms and risk of relapse. Educating the client about the need for a gradual taper ensures safe discontinuation and continuity of care.

C. Remind the client that feeling better is the therapeutic effect of the medication: Acknowledging the therapeutic benefit is important but does not provide guidance on safely stopping the medication or addressing the client’s concerns.

D. Tell the client to discuss the medication side effects with the healthcare provider (HCP): Encouraging communication with the HCP is appropriate, but the immediate priority is to inform the client that discontinuation must be gradual to prevent adverse effects.

A. Palpate flank area. B. Assess perineal area. C. Measure abdominal girth. D. Observe insertion site.

Correct Answer is D

Explanation

A. Palpate flank area: Flank assessment may help detect kidney tenderness or infection but is not the primary focus for routine suprapubic catheter care unless complications are suspected.

B. Assess perineal area: The suprapubic catheter bypasses the perineal route, so routine perineal assessment is less critical for catheter management, though general hygiene remains important.

C. Measure abdominal girth: Abdominal girth measurement is useful for detecting ascites or abdominal distention but is not directly relevant to monitoring a suprapubic catheter.

D. Observe insertion site: Regular inspection of the catheter insertion site is essential to detect signs of infection, leakage, irritation, or improper placement. This assessment helps ensure catheter function and prevents complications, making it the priority during home visits.

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A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is D

Explanation

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