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 A
Explanation
Choice A rationale
Amniotic fluid embolism is a life-threatening emergency that can lead to cardiac and respiratory failure. Immediate initiation of cardiopulmonary resuscitation (CPR) is crucial to maintain circulation and oxygenation.
Choice B rationale
Ephedrine is not typically used in the management of amniotic fluid embolism. It is a vasopressor used to treat hypotension, but it is not the primary intervention in this situation.
Choice C rationale
Assessing for the presence of clonus is not relevant in this situation. Clonus is a neurological sign and is not directly related to amniotic fluid embolism.
Choice D rationale
Assisting the client to empty their bladder is not a priority action in this situation. The immediate concern is maintaining the client’s airway, breathing, and circulation.
Correct Answer is []
Explanation
- Endometritis: The client’s symptoms such as general malaise, chills, decreased appetite, elevated white blood cell count, fever, a boggy and tender uterus, and foul-smelling lochia suggest that she is most likely experiencing endometritis, an inflammation of the inner lining of the uterus, typically due to infection.
- Actions to take: The nurse should administer the prescribed antibiotics to treat the infection. The nurse should also educate the client on proper perineal hygiene to prevent further infection.
- Parameters to monitor: The nurse should monitor the client’s temperature to assess for fever, which can be a sign of infection. The nurse should also monitor the amount and odor of the client’s lochia, as changes can indicate worsening infection.
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