A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4°C (97.6°F). Which of the following is the priority nursing action?
Initiate IV access.
Witness the signature for informed consent for surgery.
Insert an indwelling urinary catheter.
Prepare the abdominal and perineal areas.
The Correct Answer is A
Choice A reason:
In the case of a client with painless, bright red vaginal bleeding at 38 weeks of gestation, the priority is to stabilize the client's condition. Initiating IV access is crucial as it allows for rapid administration of fluids or blood products to address potential hypovolemia and to prepare for the possibility of an emergency cesarean section if needed. The client's low blood pressure and elevated heart rate suggest that she may be experiencing hypovolemia, which can quickly lead to hypovolemic shock if not treated promptly.
Choice B reason:
While obtaining informed consent is important before any surgical procedure, it is not the immediate priority. The priority is to stabilize the client, and consent can be obtained concurrently with other stabilizing actions or by another member of the healthcare team.
Choice C reason:
Inserting an indwelling urinary catheter is a supportive measure that can be necessary during labor or before surgery to keep the bladder empty, reducing the risk of bladder injury during a cesarean section and monitoring urine output as an indicator of renal perfusion. However, it is not the first priority in the presence of significant vaginal bleeding.
Choice D reason:
Preparing the abdominal and perineal areas is part of the preoperative procedure for a cesarean section. This action would follow after the client has been stabilized and a decision for surgery has been made.
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Related Questions
Correct Answer is D
Explanation
Choice A reason:
Telling a client that a pelvic exam is required for birth control pills is not accurate. Current medical guidelines indicate that a pelvic exam is not necessary to prescribe oral contraceptive medications, hormonal contraceptives can be safely prescribed based on medical history and blood pressure measurement without the need for a pelvic or breast examination.
Choice B reason:
While offering support is important, simply telling the client not to worry does not address her specific concerns or provide her with information about the process and her options.
Choice C reason:
Advising the client to relax does not acknowledge the validity of her feelings or provide her with any concrete information or support to help alleviate her anxiety.
Choice D reason:
Asking the client what part of the exam makes her most nervous is an open-ended question that invites dialogue. It allows the nurse to provide targeted information and reassurance, addressing the client's specific concerns and promoting a sense of control and participation in her own health care decisions.
Correct Answer is C
Explanation
Choice A reason:
Administering a prescribed oxytocic preparation is an important step in managing postpartum hemorrhage, as it helps to contract the uterus and reduce bleeding. However, it is not the first action a nurse should take when a client has saturated a perineal pad within 10 minutes postpartum.
Choice B reason:
Assessing the bladder for distention is also important because a full bladder can impede the contraction of the uterus and lead to increased bleeding. However, this is not the immediate action to take in the event of excessive postpartum bleeding.
Choice C reason:
Massaging the client's fundus is the first action the nurse should take. A boggy uterus, which is soft and not well contracted, can lead to excessive bleeding. Fundal massage stimulates the uterus to contract and can quickly reduce blood loss.
Choice D reason:
Assessing the client's blood pressure is vital to determine the client's hemodynamic status, but it is not the first action to take. The priority is to address the cause of the bleeding and stabilize the client.
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