A nurse in a prenatal clinic is conducting a skin assessment of a patient in her second trimester.
Which findings should the nurse anticipate? (Select all that apply.)

Choice D rationale

Facial edema, or swelling, can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. It is important for pregnant women to seek medical attention if they notice sudden or severe swelling in their face, hands, or fingers.

Choice A rationale

Inserting an indwelling urinary catheter is not the priority nursing action in this situation. While it may be necessary later in the care process, it is not the immediate concern when the client is experiencing a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. The priority is to stabilize the client and ensure the well-being of the fetus.

Choice B rationale

Witnessing the signature for informed consent for surgery is an important step before any surgical procedure. However, it is not the priority nursing action in this situation. The client’s condition could deteriorate rapidly due to the bleeding, and immediate medical interventions are necessary to stabilize the client and fetus.

Choice C rationale

Preparing the abdominal and perineal areas may be necessary if the client requires a surgical intervention. However, this is not the priority nursing action. The client is experiencing significant bleeding, and the priority is to stabilize the client’s condition.

Choice D rationale

Initiating IV access is the priority nursing action in this situation. The client is experiencing a large amount of painless, bright red vaginal bleeding, which could lead to hypovolemia and shock. IV access allows for the rapid administration of fluids and medications to stabilize the client’s condition.