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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Dry, cracked skin.
Choice A rationale:
Increased subcutaneous fat is more commonly seen in full-term infants, but post-term infants (born after 42 weeks) often have decreased subcutaneous fat due to the aging placenta’s reduced efficiency in nutrient delivery.
Choice B rationale:
Scant scalp hair is typically seen in preterm infants. Post-term infants usually have more developed features, including more scalp hair.
Choice C rationale:
Dry, cracked skin is a common finding in post-term infants because the protective vernix caseosa, which covers the skin in utero, has often been shed by this stage. The prolonged exposure to amniotic fluid can lead to skin that appears dry, cracked, and peeling.
Choice D rationale:
Copious vernix is usually seen in preterm infants. By 42.5 weeks, most of the vernix has been absorbed or shed, leading to the dry skin observed in post-term infants.
Correct Answer is D
Explanation
Choice a reason:
While ultrasound can be used for estimating fetal age, at 36 weeks of gestation, this is not the primary reason for performing an ultrasound before an amniocentesis. Fetal age is usually estimated earlier in the pregnancy to help with dating the pregnancy and determining the due date.
Choice b reason:
Determining if there is more than one fetus is typically established earlier in the pregnancy. By 36 weeks, the presence of multiples would already be known, so this would not be the primary reason for an ultrasound before an amniocentesis at this stage.
Choice c reason:
An ultrasound can be used as a screening tool for spina bifida, but it is not the main reason for an ultrasound before an amniocentesis at 36 weeks. Screening for spina bifida and other anomalies is usually done during the second trimester.
Choice d reason:
The primary reason for an ultrasound before an amniocentesis is to identify the location of the placenta and fetus. This information is crucial to ensure the safety of both the mother and the fetus during the procedure by avoiding injury to the placenta and ensuring the amniotic needle is inserted in a safe location.
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