A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations?
Decreased energy
Mood swings
Urinary frequency
Facial edema
The Correct Answer is D
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Related Questions
Correct Answer is D
Explanation
The nurse's first action should be to massage the client's fundus, as this can help stimulate uterine contraction and prevent hemorrhage. The fundus is the upper part of the uterus that contracts and involutes after delivery to compress the blood vessels and stop bleeding. The nurse should palpate the fundus for firmness, height, and position, and massage it gently if it is boggy or displaced.
The other actions are not the first priority and may be done after massaging the fundus.
The nurse should observe for the pooling of blood under the buttocks, as this can indicate a large amount of blood loss that may not be visible on the perineal pad. However, this is not the first action to take, as it does not address the cause of the bleeding or stop it from continuing.
The nurse should assess the client's blood pressure, as this can indicate the severity of blood loss and the presence of shock. However, blood pressure may not change significantly until a large amount of blood is lost, and it is not specific to the cause of bleeding. Therefore, blood pressure is not the first action to take.
The nurse should prepare to administer a prescribed oxytocic preparation, such as oxytocin or methylergonovine, as this can enhance uterine contraction and reduce bleeding. However, this requires a provider's order and may take time to obtain and administer. Therefore, an oxytocic preparation is not the first action to take.
Correct Answer is D
Explanation
The GTPAL system is a way of describing a woman's obstetric history using five digits: G (gravida), T (term births), P (preterm births), A (abortions), and L (living children). The client's present parity can be calculated as follows:
G: The client is gravida 4, as she has been pregnant four times, including the current one.
T: The client has had one term birth, as she delivered twins at 36 weeks, which is considered term for a multiple gestation.
P: The client has had no preterm births, as she has not delivered any babies before 37 weeks of gestation. A: The client has had two abortions, one elective and one spontaneous, both before 20 weeks of gestation. L: The client has two living children, the twins she delivered at term.
Therefore, the client's present parity is 2-0-1-2-2.
The other options are incorrect and do not reflect the client's obstetric history.
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