A nurse is caring for a 32-year-old female client who is at 32 weeks of gestation and has complete placenta previa. The client is in the obstetric unit.
Which of the following assessment findings requires immediate follow-up? Select all that apply.
Hematocrit
Fundal height
Vaginal bleeding
Platelet count
Fetal heart rate
Correct Answer : A,C,E
Choice A rationale: The client’s hematocrit level is 27%, which is below the normal range (greater than 39%). This could indicate anemia, which can be caused by blood loss. Given the client’s report of a “gush” of blood and the nurse’s observation of a moderate amount of bright red vaginal bleeding, this is a concerning finding that requires immediate follow-up. Anemia in pregnancy can lead to complications such as preterm birth, low birth weight, and maternal mortality.
Choice B rationale: The client’s fundal height is 33 cm, which is appropriate for a gestational age of 33 weeks. Fundal height is measured from the top of the pubic bone to the top of the uterus, and in centimeters, it should roughly equal the number of weeks of gestation. Therefore, this finding does not require immediate follow-up.
Choice C rationale: The client reports feeling a “gush” of blood and the nurse observes a moderate amount of bright red vaginal bleeding. This is a concerning finding given the client’s diagnosis of complete placenta previa, a condition where the placenta
completely covers the cervix. Vaginal bleeding in this context can indicate placental abruption, a serious complication where the placenta detaches from the uterus before childbirth. This requires immediate follow-up.
Choice D rationale: The client’s platelet count is 160,000/mm³, which is within the normal range (150,000 to 400,000/mm³). This indicates that the client’s blood clotting function is currently adequate. While platelet count can decrease with significant blood loss, the client’s current platelet count does not indicate a potential complication of pregnancy.
Choice E rationale: The client’s fetal heart rate is 174/min, which is above the normal range (110 to 160/min). This could indicate fetal tachycardia, which can be a response to maternal blood loss, maternal fever, or fetal hypoxia. This is a concerning finding that requires immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A blood pressure of 88/40 mm Hg is significantly lower than the normal range, which could indicate hemorrhage. Hypotension is a common sign of significant blood loss.
Choice B rationale
Moderate rubra lochia is normal within the first few days postpartum and does not necessarily indicate hemorrhage.
Choice C rationale
A heart rate of 90/min is within the normal range and does not indicate hemorrhage.
Choice D rationale
A urinary output of 40 mL/hr is within the normal range and does not indicate hemorrhage.
Correct Answer is A
Explanation
Choice A rationale
Facial asymmetry can occur as a result of a forceps-assisted birth. The pressure from the forceps can cause temporary changes in the shape of the baby’s face.
Choice B rationale
Caput succedaneum, a swelling of the scalp in a newborn, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice C rationale
Cephalohematoma, a bleeding underneath one of the cranial bones, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice D rationale
Subgaleal hemorrhage, bleeding into the space between the skull periosteum and the scalp galea aponeurosis, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
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