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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Taking charge of all mothering tasks is more indicative of the “taking-hold” phase, which typically occurs a few days after birth.
Choice B rationale
Desiring privacy with the newborn is not specifically indicative of the “taking-in” phase.
Choice C rationale
Putting personal needs aside is not specifically indicative of the “taking-in” phase.
Choice D rationale
Reviewing the birth experience with others is indicative of the “taking-in” phase. During this phase, the new mother is often passive and somewhat dependent, and she may need to review her childbirth experience as a way to fully grasp her new role.
Correct Answer is A
Explanation
Choice A rationale
Changing the perineal pad only once daily can lead to an increased risk of infection, which can delay wound healing. It’s important to maintain cleanliness in the perineal area, especially after a laceration, to promote healing.
Choice B rationale
Cleaning the perineum with a squeeze bottle after urinating is actually a recommended practice. It helps to keep the area clean and reduce the risk of infection.
Choice C rationale
A well-approximated perineal suture line is a positive sign of healing. It indicates that the edges of the wound are close together, which promotes healing and reduces the risk of infection.
Choice D rationale
Using witch hazel pads on the perineum can provide relief from discomfort and has astringent properties that can promote healing.
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