A nurse is assisting with the care of a 19-year-old female client who is at 18 weeks of gestation in the emergency department.

Exhibits

Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Choice A rationale

"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.

Choice B rationale

"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.

Choice C rationale

"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.

Choice D rationale

"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.

Choice A rationale

Bleeding gums can be common during pregnancy due to increased blood flow and hormonal changes that affect the gums, causing them to be more sensitive and prone to bleeding. It's usually not a cause for immediate concern unless it's severe or accompanied by other symptoms.

Choice B rationale

Abdominal cramping at 26 weeks of gestation could indicate preterm labor or other complications, such as placental abruption. It's a significant symptom that needs immediate medical attention to ensure both maternal and fetal well-being.

Choice C rationale

White vaginal discharge, known as leukorrhea, is common during pregnancy due to increased production of estrogen and greater blood flow to the vaginal area. It helps prevent infections and usually does not indicate a problem unless it has a foul odor or is accompanied by itching or irritation.

Choice D rationale

Asymptomatic palpitations are relatively common during pregnancy due to increased blood volume and changes in circulation. They usually don't indicate a serious problem unless they're severe, persistent, or accompanied by other symptoms like chest pain or shortness of breath.