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.

Exhibits

Which of the following assessment findings requires immediate follow-up? Select all that apply.

Hematocrit

Fundal height

Vaginal bleeding

Platelet count

Fetal heart rate

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: Ensuring the call button is within the client's reach is important for general patient safety and communication, but it is not the highest priority for seizure precautions.

Choice B rationale: Placing suction equipment at the client's bedside is crucial for managing airway secretions during a seizure. Having suction equipment readily available ensures that the client's airway can be cleared promptly, which is vital for maintaining breathing and preventing aspiration.

Choice C rationale: Dimming the lights in the client's room can help reduce stimuli that may trigger seizures, but it is not the most urgent action to take when implementing seizure precautions.

Choice D rationale: Padding the side rails of the client's bed is important to prevent injury during a seizure, but ensuring that suction equipment is available takes priority to maintain airway patency and prevent complications.

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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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. Exhibits Which of the following assessment findings requires immediate follow-up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse’s priority when implementing seizure precautions?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

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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.

Exhibits

Which of the following assessment findings requires immediate follow-up? Select all that apply.