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.

Exhibits

Which of the following assessment findings requires immediate follow-up? Select all that apply.

Hematocrit

Fundal height

Vaginal bleeding

Platelet count

Fetal heart rate

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

A Coombs positive result does not necessarily mean that the newborn will require immediate intervention. It indicates that the newborn should be monitored for potential complications such as jaundice and anemia.
Choice B rationale
While the newborn’s glucose level is within the normal range, this does not directly relate to the Coombs positive result.
Choice C rationale
A Coombs positive result may indicate Rh or ABO incompatibility, but this does not directly answer the question of what the nurse should anticipate.
Choice D rationale
This is the correct answer. A Coombs positive result indicates that the newborn should be monitored for signs of jaundice, as this could be a potential complication.

Correct Answer is []

Explanation

• Hyperemesis gravidarum: The client’s symptoms such as severe nausea and vomiting, inability to retain clear fluids, and positive ketones in urinalysis suggest that she is most likely experiencing hyperemesis gravidarum, a pregnancy complication characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance.
• Actions to take: The nurse should administer the prescribed antiemetic medication to help control the client’s nausea and vomiting. The nurse should also provide IV fluid replacement to correct the client’s dehydration and electrolyte imbalance.
• Parameters to monitor: The nurse should monitor the client’s urine output to assess her hydration status. The nurse should also monitor the client’s electrolyte levels, as electrolyte imbalances can occur with severe vomiting and dehydration. If the client’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.

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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. Exhibits Which of the following assessment findings requires immediate follow-up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hours old. The newborn has a Coombs positive result and a glucose level of 50 mg/dL (40 to 60 mg/dL). What should the nurse anticipate?

Correct Answer is D

Explanation

Correct Answer is []

Explanation

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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.

Exhibits

Which of the following assessment findings requires immediate follow-up? Select all that apply.