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 A

Explanation

The correct answer is choice A. Uteroplacental insufficiency.

Choice A rationale:

Late decelerations on a fetal monitor strip are typically indicative of uteroplacental insufficiency. This condition occurs when the placenta is not delivering enough oxygen to the fetus, often due to issues like placental abruption, preeclampsia, or post-term pregnancy.

Choice B rationale:

Maternal bradycardia refers to a slow heart rate in the mother, which is not directly related to late decelerations in the fetal heart rate. Late decelerations are specific to fetal distress due to placental issues.

Choice C rationale:

Umbilical cord compression usually causes variable decelerations, not late decelerations. Variable decelerations are abrupt decreases in fetal heart rate that can occur at any time during a contraction.

Choice D rationale:

Fetal head compression typically results in early decelerations, which are gradual decreases in fetal heart rate that mirror the contractions. These are generally not concerning and are considered a normal response to labor.

A. Notify the provider of the findings. B. Position the client with one hip elevated. C. Have the client void. D. Ask the client if she needs pain medication.

Correct Answer is B

Explanation

Choice A reason:
Notifying the provider of the findings is important, but it is not the immediate priority. The provider should be informed after initial measures to stabilize the client's condition have been taken.

Choice B reason:
Positioning the client with one hip elevated, also known as the lateral or left-lateral position, is the priority action. This position can help improve blood flow and potentially increase the maternal blood pressure, which is critically low at 92/54 mm Hg. It also helps to optimize uteroplacental perfusion, which is essential for the well-being of both the mother and the fetus.

Choice C reason:
Having the client void can be helpful in preventing bladder distention, which can interfere with labor progress. However, it is not the priority action when the client's blood pressure is significantly low.

Choice D reason:
Asking the client if she needs pain medication is an important part of comfort care during labor. However, addressing the client's low blood pressure is a more immediate concern to prevent potential complications for both the mother and the fetus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make?

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?