A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?

Rationale:

A. Nurses notes are used to create the critical pathway: Critical pathways are developed from evidence-based clinical guidelines and best practices, not directly from nurses’ notes. While documentation may help track progress, it is not the foundation for pathway creation.

B. Critical pathways should reduce health care costs: Critical pathways standardize care for specific diagnoses, promoting timely interventions and reducing unnecessary treatments or delays. This efficiency helps lower healthcare costs while improving patient outcomes.

C. Critical pathways have an unlimited timeframe for completion: Each critical pathway includes a defined timeline with expected outcomes for each phase of care. This structure ensures care is efficient and progress is monitored closely to prevent delays or complications.

D. Nurses should discontinue the critical pathway if variances occur: Variances are deviations from the expected outcomes and are used to evaluate and adjust care. They do not justify discontinuing the entire pathway but rather indicate a need for reassessment or individualized modifications.

Rationale for correct choices:

• Placental abruption: Hypertension in pregnancy increases the risk of premature separation of the placenta from the uterine wall. In this case, the elevated BP combined with symptoms like right upper quadrant pain and hyperreflexia suggests a potential complication such as placental abruption.
• Hypertension: A blood pressure of 148/94 mm Hg is above the diagnostic threshold for gestational hypertension. When paired with signs like restlessness, headache, and hyperreflexia, it raises concern for preeclampsia, a known risk factor for placental abruption.

Rationale for incorrect choices:

• Placenta previa: Characterized by painless bleeding in the second or third trimester and associated with abnormal placental placement, not hypertension. The client has no bleeding or ultrasound findings consistent with previa.
• Oligohydramnios: Typically linked to fetal or placental insufficiency or rupture of membranes. No findings in this case suggest low amniotic fluid or related complications.
• Spontaneous abortion: This term applies before 20 weeks’ gestation. The client is 30 weeks pregnant with no signs of fetal demise or expulsion, so this condition does not apply.
• Chorioamnionitis: Requires signs of infection such as fever, uterine tenderness, or foul-smelling discharge. The client is afebrile and has clear lung sounds, making infection unlikely.
• Temperature: The recorded temperature is within normal range (37.4°C), so it does not suggest infection or another abnormality requiring urgent follow-up.
• Vomiting: Common in pregnancy and non-specific unless persistent or linked with abnormal labs. Here, it appears as an isolated symptom and does not directly imply risk of abruption.
• Hyperreflexia: While a sign of preeclampsia, it is secondary to hypertension. It supports the presence of a hypertensive disorder but is not the primary cause of abruption.
• Fundal measurement: A fundal height of 29 cm is normal for 30 weeks’ gestation and does not indicate fetal growth restriction or excess fluid that might signal a complication.