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 C

Explanation

Choice A rationale
Leukorrhea, or vaginal discharge, is a common occurrence in pregnancy due to hormonal changes, but it is not a specific sign of abruptio placentae.
Choice B rationale

Hypertension can be a risk factor for abruptio placentae, but it is not a direct sign of the condition.
Choice C rationale
Uterine tenderness is a common symptom of abruptio placentae. This condition, which involves the premature separation of the placenta from the uterus, can cause the uterus to become irritable and sensitive to touch.
Choice D rationale
Fetal tachycardia can be a sign of fetal distress, which could be a result of various complications in pregnancy, including abruptio placentae. However, it is not a specific sign of abruptio placentae.

A. Intramuscular in the right deltoid B. Subcutaneous in the right deltoid C. Intramuscular in the left vastus lateralis D. Subcutaneous in the left vastus lateralis .

Correct Answer is C

Explanation

Choice A rationale
Intramuscular injection in the right deltoid is not the preferred route for administering phytonadione to a newborn.
Choice B rationale
Subcutaneous injection in the right deltoid is not the preferred route for administering phytonadione to a newborn.
Choice C rationale
Intramuscular injection in the left vastus lateralis is the preferred route for administering phytonadione to a newborn. This muscle in the thigh is large enough to absorb the medication effectively.
Choice D rationale
Subcutaneous injection in the left vastus lateralis is not the preferred route for administering phytonadione to a newborn.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in labor who is experiencing abruptio placentae. What findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is preparing to administer phytonadione 0.5 mg to a newborn. What routes should the nurse choose for administration of the medication?

Correct Answer is C

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.