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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Telling a grieving mother that not holding her baby will make letting go much harder can be seen as insensitive and may not be true for all individuals. Each person’s grief process is unique.
Choice B rationale
Assuring the mother that she will be able to have another baby when she’s ready may be seen as dismissive of her current loss. It’s important to acknowledge the pain of losing this specific child, rather than focusing on future children.
Choice C rationale
This is the correct answer. Offering the mother the opportunity to bathe and dress her baby can provide a sense of closure and a chance to say goodbye. It allows the mother to care for her baby in the short time they have together.
Choice D rationale
While some parents may find comfort in naming their baby, it should not be presented as something the mother “should” do. The decision to name the baby is a personal one and should be left up to the parents.
Correct Answer is D
Explanation
The correct answer is choiced. Inform the client about the possible need for reduction of multiple fetuses.
Choice A rationale:
Instructing the client not to use donor oocytes is not accurate.Donor oocytes can be a viable option for clients with certain infertility issues, such as ovarian insufficiency or genetic concerns.
Choice B rationale:
Informing the client that sperm will be introduced to the uterus during ovulation is incorrect.In vitro fertilization involves fertilizing the eggs outside the body in a laboratory setting, not directly introducing sperm into the uterus.
Choice C rationale:
Instructing the client to avoid freezing embryos for possible use in the future is not appropriate.Freezing embryos is a common practice in IVF to allow for future attempts if the initial cycle is unsuccessful.
Choice D rationale:
Informing the client about the possible need for reduction of multiple fetuses is correct.IVF can result in multiple pregnancies, and in some cases, fetal reduction may be recommended to ensure the health and safety of the mother and remaining fetuses.
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