A nurse is assisting with the care of a client who is at 28 weeks of gestation.
Complete the diagram by dragging 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.
The Correct Answer is []
- Potential Condition: Placenta previa
- This condition is characterized by the placenta covering the cervix, which can lead to painless, bright red vaginal bleeding during the second or third trimester.
- Actions to Take:
1. Insert a large-bore peripheral IV catheter.
- This is a precautionary measure to ensure that there is immediate venous access for fluid and blood product administration if necessary.
2. Reinforce with the client to maintain bed rest.
- Limiting physical activity can help reduce the risk of further bleeding.
- Parameters to Monitor:
1. Vaginal bleeding
- Monitoring the amount, color, and frequency of bleeding is crucial to assess the ongoing blood loss and stability of the condition.
2. Fetal well-being
- Regular monitoring of fetal heart rate and movement is important to ensure the fetus is not in distress.
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Related Questions
Correct Answer is D
Explanation
A. Leukorrhea, a normal increase in vaginal discharge, is a common and expected finding during pregnancy. It usually does not require immediate medical intervention unless accompanied by other symptoms.
B. Gingivitis is a common issue during pregnancy due to hormonal changes, but it is generally managed with good oral hygiene and routine dental care. It is not an urgent finding compared to other conditions.
C. Varicose veins are a common condition during pregnancy due to increased blood volume and pressure on the veins. While they can be uncomfortable, they are generally managed through lifestyle changes and do not represent an immediate risk.
D. Dysuria, or painful urination, may indicate a urinary tract infection or another serious condition that requires prompt medical attention. It can lead to complications if untreated, so it is a priority finding that needs to be reported to the provider for further evaluation and treatment.
Correct Answer is A
Explanation
A. Chronic hypertension is a significant risk factor for preeclampsia. Pregnant clients with pre-existing high blood pressure are at increased risk for developing this condition, which can lead to complications for both the mother and the baby.
B. Maternal age of 30 years is not considered a high-risk factor for preeclampsia. Advanced maternal age (35 years and older) is more commonly associated with an increased risk.
C. The third pregnancy alone is not a risk factor for preeclampsia. First pregnancies or a history of preeclampsia in previous pregnancies are more relevant risk factors.
D. A prepregnancy BMI of 19 is within the normal weight range and is not associated with an increased risk of preeclampsia. Obesity or a high BMI is more closely linked to the development of preeclampsia.
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