A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.

Exhibits

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

A. Give oxytocin 20 units IV bolus: Oxytocin is a medication used to induce or augment labor, and it is not the appropriate intervention for a client with placenta previa and significant vaginal bleeding. The priority in this situation is to assess and manage the bleeding.

B. Obtain serial hemoglobin and hematocrit: This is the correct action. Placenta previa can lead to significant bleeding, and obtaining serial hemoglobin and hematocrit levels will help monitor the extent of blood loss and guide decisions regarding transfusions or other interventions.

C. Perform a fundal massage: Fundal massage is not the appropriate intervention for placenta previa. In cases of placenta previa, the placenta is covering or near the cervical os, and vigorous fundal massage can worsen bleeding.

D. Assess for abdominal tenderness: While assessing for abdominal tenderness is important in the overall assessment of a pregnant client, in the context of active bleeding with placenta previa, the immediate focus should be on assessing the extent of bleeding and the client's hemodynamic status.

A. Yellowed sclera : Yellowed sclera (the white part of the eyes) can indicate jaundice in a newborn. Jaundice is caused by elevated levels of bilirubin and may signify various underlying conditions, including an excessive breakdown of red blood cells, liver immaturity, or other issues. Prompt notification of the healthcare provider is necessary to evaluate and manage jaundice appropriately.

B. Stooling after each breastfeeding: Stooling after each breastfeeding session is a common and expected occurrence in newborns. Breastfed babies often pass stools frequently, and this is generally not a cause for concern unless there are other associated symptoms.

C. Intermittent crossing of eyes: Occasional intermittent crossing of eyes can be normal in newborns. However, if persistent or accompanied by other concerning signs, it might require evaluation, but it's not typically an immediate concern.

D. Voids eight to ten times per day: A healthy newborn typically voids frequently throughout the day. Eight to ten times per day is within the expected range for a newborn's urinary output and might not be a cause for immediate concern.