The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is:
Monitor uterine contractions.
Assess fetal heart rate (FHR) and maternal vital signs.
Perform a venipuncture for hemoglobin and hematocrit levels.
Place clean disposable pads to collect any drainage.
The Correct Answer is B
Choice A) Monitor uterine contractions is incorrect because this is not the most urgent intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Uterine contractions can indicate labor or placental abruption, which are possible causes of bleeding in late pregnancy. However, they are not the only or the most reliable indicators of these conditions, as some women may have painless bleeding or contractions without bleeding. Moreover, monitoring uterine contractions does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Choice B) Assess fetal heart rate (FHR) and maternal vital signs is correct because this is the most important and essential intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Bleeding in late pregnancy can be caused by various conditions, such as placenta previa, placental abruption, uterine rupture, or vasa previa, which can compromise the blood supply and oxygen delivery to the mother and the fetus. Assessing FHR and maternal vital signs can help to determine the severity and cause of the bleeding, as well as guide further
interventions such as fluid resuscitation, oxygen therapy, blood transfusion, or emergency delivery. The normal FHR range for a fetus is 110 to 160 beats per minute, and it may vary with fetal activity or maternal position. The normal maternal vital signs are: blood pressure 120/80 mm Hg or lower, heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, and temperature 36.5°C to 37.5°C (97.7°F to 99.5°F). Any deviation from these ranges may indicate hypoxia, hypovolemia, shock, infection, or distress. Therefore, this intervention should be done as soon as possible for women who have bleeding in late pregnancy.
Choice c) Perform a venipuncture for hemoglobin and hematocrit levels is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Hemoglobin and hematocrit are blood tests that measure the amount of red blood cells and their percentage in the blood volume.
They can help to evaluate the extent of blood loss and the need for blood transfusion. However, they are not
immediate or accurate indicators of bleeding in late pregnancy, as they may take time to reflect the changes in blood volume or be affected by other factors such as hydration or hemodilution. Moreover, performing a venipuncture does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion.
Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Choice d) Place clean disposable pads to collect any drainage is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Placing clean disposable pads can help to keep the perineal area clean and dry, as well as to estimate the amount and type of bleeding. However, it does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Moreover, it does not provide any information about the cause or severity of the bleeding, as it may be affected by factors such as gravity or pooling. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A) Increased urinary output: This is not a sign of sepsis in newborns. In fact, sepsis can cause reduced urinary output due to poor blood flow to the kidneys and dehydration.
Choice B) Hypothermia: This is a sign of sepsis in newborns. Sepsis can cause changes in temperature, often fever, but sometimes low temperature. Hypothermia can indicate a severe infection that affects the body's ability to regulate its temperature.
Choice C) Wakefulness: This is not a sign of sepsis in newborns. Sepsis can cause reduced activity and lethargy due to inflammation and organ dysfunction.
Choice D) Interest in feeding: This is not a sign of sepsis in newborns. Sepsis can cause reduced sucking and difficulty feeding due to poor appetite, nausea, vomiting, and abdominal distension.
Correct Answer is B
Explanation
Choice A: This is incorrect because acetylsalicylic acid (ASA), also known as aspirin, is not a cure for preeclampsia, but a preventive measure. ASA may reduce the risk of preeclampsia in some high-risk women by inhibiting platelet aggregation and improving blood flow to the placenta. However, ASA is not recommended for all pregnant women, as it may have adverse effects on the mother and the fetus, such as bleeding, premature closure of the ductus arteriosus, or fetal growth restriction.
Choice B: This is the correct answer because delivery of the fetus is the only definitive treatment for preeclampsia, as it eliminates the source of the placental factors that cause the condition. Preeclampsia is a multisystem disorder characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is caused by abnormal placentation and endothelial dysfunction that lead to vasoconstriction, inflammation, and coagulation.
Delivery of the fetus and the placenta resolves these abnormalities and restores normal maternal physiology.
Choice C: This is incorrect because antihypertensive medications are not a cure for preeclampsia, but a symptomatic management. Antihypertensive medications may lower the blood pressure and reduce the risk of maternal complications, such as stroke, seizure, or organ damage. However, antihypertensive medications do not address the underlying cause of preeclampsia and do not improve fetal outcomes. Moreover, some antihypertensive medications are contraindicated in pregnancy due to their teratogenic effects.
Choice D: This is incorrect because magnesium sulfate is not a cure for preeclampsia, but a prophylaxis for eclampsia. Eclampsia is a severe complication of preeclampsia that involves seizures and coma. Magnesium sulfate is an anticonvulsant that prevents or treats eclamptic seizures by stabilizing neuronal membranes and reducing cerebral edema. However, magnesium sulfate does not lower blood pressure or improve renal function in preeclamptic women. It also has side effects such as nausea, flushing, headache, or respiratory depression.
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