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 C

Explanation

Choice A rationale
Raw carrots do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice B rationale
Fresh citrus fruits do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice C rationale
This is the correct answer. Fortified soy milk is a good source of vitamin B12 for vegans. Many brands of soy milk are fortified with vitamin B12 and other nutrients to help vegans meet their nutritional needs.
Choice D rationale
Brown rice does not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.

A. Apply hydrating lotion to the newborn’s skin prior to treatment. B. Provide the newborn with 15 mL glucose water after each feeding. C. Turn the newborn every 4 hours. D. Close the newborn’s eyes before applying eyepatches.

Correct Answer is D

Explanation

Choice A rationale

Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The goal of phototherapy is to expose the newborn’s skin to light, and applying lotion could potentially interfere with the effectiveness of the treatment.
Choice B rationale
Providing the newborn with 15 mL glucose water after each feeding is not a standard part of phototherapy treatment. The newborn should continue to receive regular feedings, but additional glucose water is not typically necessary.
Choice C rationale
Turning the newborn every 4 hours is not sufficient during phototherapy. The newborn should be repositioned frequently, ideally every 2-3 hours, to expose all areas of the skin to the light.
Choice D rationale
It is important to protect the newborn’s eyes during phototherapy to prevent damage from the light. Therefore, the newborn’s eyes should be covered with special patches whenever the lights are on.

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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.

Nursing Test Bank

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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.