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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Correct Answer is B
Explanation
Choice A reason:
Monitoring weight gain during pregnancy is important to ensure that the mother and baby are healthy. The expected weight gain during pregnancy varies depending on the mother's pre-pregnancy weight, but generally, a total gain of 25 to 35 pounds is considered normal for women of average weight.
Choice B reason:
While some nonprescription medications are safe during pregnancy, not all are, and it is crucial to consult with a healthcare provider before taking any medication, including over-the-counter ones. Certain medications can cause harm to the developing fetus and may lead to complications such as birth defects or other adverse outcomes.
Choice C reason:
Reducing stress is beneficial during pregnancy as high levels of stress can negatively impact both the mother and the developing fetus. Stress can lead to increased risks of preterm birth and low birth weight, and it can affect the baby's development. Therefore, implementing stress-reduction techniques is a positive step for a pregnant woman.
Choice D reason:
Informing the doctor before using home remedies for nausea is advisable. While many home remedies are safe and can be effective, such as ginger and peppermint, it is always best to discuss them with a healthcare provider to ensure they are appropriate and will not interfere with the pregnancy.
Correct Answer is C
Explanation
Choice a reason:
A male condom is a barrier method of contraception that is typically easy to use and accessible. It has the added benefit of providing protection against sexually transmitted infections (STIs). However, its effectiveness can be compromised by improper use or breakage. With typical use, male condoms are about 85% effective.
Choice b reason:
A diaphragm with spermicide is another barrier method that can be used to prevent pregnancy. The diaphragm covers the cervix and the spermicide kills or immobilizes sperm. The effectiveness of a diaphragm with spermicide is generally lower than some other methods, with typical use effectiveness around 88%.
Choice c reason:
An intrauterine device (IUD) is a small device inserted into the uterus by a healthcare provider. IUDs come in two types: hormonal and copper. Both types are highly effective, with over 99% effectiveness. They are long-acting, reversible, and do not require daily attention, which contributes to their reliability.
Choice d reason:
An oral contraceptive, also known as the birth control pill, is a popular method of contraception that requires the user to take a pill at the same time every day. The effectiveness of the pill can be high, but because it relies on user adherence, its typical use effectiveness is around 91%.
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