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 C
Explanation
Hand hygiene is one of the most important infection prevention strategies in the NICU, and parents and visitors should be encouraged to wash their hands frequently, especially before touching the newborn. While wearing gloves can provide an additional barrier against infection, it is not a substitute for hand hygiene. Family members should be encouraged to visit and bond with their newborn, but they should be taught proper infection prevention measures to protect the infant's health. Avoiding direct contact with the newborn is not necessary as long as appropriate infection-prevention measures are taken.
Correct Answer is B
Explanation
Epidural blocks are commonly used during labor to provide pain relief. However, they can also cause a sudden drop in blood pressure, known as epidural-induced hypotension, which can affect fetal oxygenation and fetal heart rate. Therefore, it is important to monitor maternal blood pressure frequently after an epidural block is administered.
While monitoring the maternal pulse is also important, hypotension is the most common complication of epidural anesthesia and can lead to decreased blood flow to the fetus. Therefore, monitoring maternal blood pressure is the priority.
Monitoring the fetus is also important, but it is not the most important intervention after an epidural block. Limiting parenteral fluids may be necessary in some cases to help prevent or treat hypotension, but it is not always necessary and should be done based on the individual situation.
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