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.

Answer and Explanation

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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Correct Answer is D

Explanation

The correct answer is choice D: Document the findings and continue to monitor the client.

Rationale:

Choice A: While encouraging the client to empty her bladder is important to help with uterine contraction, it's not the priority in this situation. The client's fundus is firm and midline, indicating good uterine contraction.

Choice B: Increasing the frequency of fundal massage is not necessary when the fundus is firm and midline. Excessive fundal massage can lead to uterine fatigue and decreased contractility.

Choice C: Notifying the client's provider is not necessary for a moderate amount of lochia rubra and small clots in the early postpartum period. This is a normal finding.

Choice D: Documenting the findings and continuing to monitor the client is the correct action. The nurse should document the amount, color, and consistency of lochia, as well as the fundus assessment. The client should be monitored closely for any signs of excessive bleeding or uterine atony.

A. Elevated blood pressure B. Joint pain C. Vaginal discharge D. Increased urine output

Correct Answer is A

Explanation

Choice a reason:
Elevated blood pressure is a primary indicator for preeclampsia, which is a condition characterized by hypertension and often proteinuria after 20 weeks of gestation. The criteria for hypertension in pregnancy are a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least 4 hours apart. If a pregnant client presents with elevated blood pressure, it is crucial for the nurse to initiate further evaluation for preeclampsia, as this condition can lead to serious complications for both the mother and the fetus.

Choice b reason:
Joint pain is not a typical sign of preeclampsia. While joint pain can be a symptom experienced during pregnancy due to various physiological changes, it is not specifically associated with preeclampsia and does not warrant further evaluation for this disorder on its own.

Choice c reason:
Vaginal discharge during pregnancy is common and can vary in consistency and amount. It is not a specific indicator of preeclampsia unless accompanied by other symptoms such as elevated blood pressure or proteinuria. Normal vaginal discharge is usually clear or milky white and does not indicate the need for preeclampsia evaluation.

Choice d reason:
Increased urine output is not typically associated with preeclampsia. In fact, preeclampsia can sometimes lead to reduced urine output due to kidney impairment. If a client has increased urine output, it may be due to other factors such as increased fluid intake or gestational diabetes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the level of the umbilicus. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct Answer is A

Explanation

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who is at 36 weeks of gestation and has a suspected placenta previa. Which of the following findings support this diagnosis?

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?