A nurse is caring for a 32-year-old female client who is at 32 weeks of gestation and has complete placenta previa. The client is in the obstetric unit.
Which of the following assessment findings requires immediate follow-up? Select all that apply.
Hematocrit
Fundal height
Vaginal bleeding
Platelet count
Fetal heart rate
Correct Answer : A,C,E
Choice A rationale: The client’s hematocrit level is 27%, which is below the normal range (greater than 39%). This could indicate anemia, which can be caused by blood loss. Given the client’s report of a “gush” of blood and the nurse’s observation of a moderate amount of bright red vaginal bleeding, this is a concerning finding that requires immediate follow-up. Anemia in pregnancy can lead to complications such as preterm birth, low birth weight, and maternal mortality.
Choice B rationale: The client’s fundal height is 33 cm, which is appropriate for a gestational age of 33 weeks. Fundal height is measured from the top of the pubic bone to the top of the uterus, and in centimeters, it should roughly equal the number of weeks of gestation. Therefore, this finding does not require immediate follow-up.
Choice C rationale: The client reports feeling a “gush” of blood and the nurse observes a moderate amount of bright red vaginal bleeding. This is a concerning finding given the client’s diagnosis of complete placenta previa, a condition where the placenta
completely covers the cervix. Vaginal bleeding in this context can indicate placental abruption, a serious complication where the placenta detaches from the uterus before childbirth. This requires immediate follow-up.
Choice D rationale: The client’s platelet count is 160,000/mm³, which is within the normal range (150,000 to 400,000/mm³). This indicates that the client’s blood clotting function is currently adequate. While platelet count can decrease with significant blood loss, the client’s current platelet count does not indicate a potential complication of pregnancy.
Choice E rationale: The client’s fetal heart rate is 174/min, which is above the normal range (110 to 160/min). This could indicate fetal tachycardia, which can be a response to maternal blood loss, maternal fever, or fetal hypoxia. This is a concerning finding that requires immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Uterine hypertonicity is not typically associated with placenta previa. Hypertonicity refers to an overly active uterus with contractions that are too strong, too long, or too close together.
Choice B rationale
Painless vaginal bleeding is a classic symptom of placenta previa. The bleeding is usually bright red and can be heavy.
Choice C rationale
Persistent headache is not a typical symptom of placenta previa. It is more commonly associated with conditions like preeclampsia.
Choice D rationale
Fetal distress is not a direct symptom of placenta previa, but it can occur if the placenta is not providing enough oxygen and nutrients to the fetus.
Correct Answer is D
Explanation
Choice A rationale
While breast tenderness can be a side effect of oral contraceptives, it is not typically a sign of a serious problem. It may occur as the body adjusts to the hormones in the medication.
However, if the tenderness is severe or persists, the client should consult their healthcare provider.
Choice B rationale
Pain during intercourse is not typically associated with the use of oral contraceptives. If a client experiences this symptom, it may be due to other causes such as infection, inflammation, or certain medical conditions. It’s important to seek medical advice if this symptom occurs.
Choice C rationale
Unusual vaginal discharge can be a side effect of oral contraceptives, but it is not typically a sign of a serious problem. Changes in the color, consistency, or smell of vaginal discharge could indicate an infection or other medical condition and should be evaluated by a healthcare provider.
Choice D rationale
Severe abdominal pain is a symptom that the client should report to the provider immediately. This could be a sign of a serious problem such as a blood clot or liver disease. It’s important to seek immediate medical attention if this symptom occurs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.