What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?
Assessing fetal heart rate (FHR) and maternal vital signs
Performing a venipuncture for hemoglobin and hematocrit levels
Monitoring uterine contractions
Placing clean disposable pads to collect any drainage
The Correct Answer is A
Assessing fetal heart rate (FHR) and maternal vital signs would be the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy. This is because fetal distress or maternal instability may require immediate medical intervention, such as delivery via emergency cesarean section or blood transfusions, respectively.
Therefore, assessing the FHR and maternal vital signs will help to determine the urgency of the situation and guide the next steps in the management of the patient. Once the patient's condition has stabilized, performing venipuncture for hemoglobin and hematocrit levels, monitoring uterine contractions, and placing clean disposable pads to collect any drainage can be done as appropriate.
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Related Questions
Correct Answer is A
Explanation
Based on the provided information, the probable diagnosis for the spontaneous abortion in this woman would be a threatened abortion, since the cervix is closed and there is no evidence of expulsion of fetal or placental tissue. A threatened abortion is defined as vaginal bleeding occurring before the 20th week of gestation, with a closed cervical os, and no expulsion of fetal or placental tissue.
The other types of spontaneous abortion are defined as follows:
B. Inevitable abortion: vaginal bleeding and cramping with an open cervical os, with or without expulsion of fetal or placental tissue
C. Missed abortion: fetal demise without expulsion of fetal tissue, and may be associated with a closed cervical os and absence of uterine contractions
D. Incomplete abortion: partial expulsion of fetal or placental tissue, with or without vaginal bleeding, and may be associated with an open cervical os and uterine contractions
Correct Answer is C
Explanation
Nifedipine is a calcium channel blocker that can cause hypotension as a side effect, so the client should be advised to rise slowly from a sitting or lying position to avoid dizziness or fainting. The client does not necessarily need to be hospitalized and should continue taking the medication until a healthcare provider advises otherwise. The medication is typically continued until around 36-37 weeks gestation. There is no need to monitor respiratory rate with this medication.
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