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A nurse is caring for a client.

Exhibits

Select the 2 actions that the nurse should take.

A.

Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP)

B.

Obtain serial H&H and clotting studies.

C.

Administer misoprostol 600 mg rectally.

D.

Place the client in a supine position.

E.

Prepare to transfuse 2 units of packed RBCs.

Answer and Explanation

Correct Answer : A,E

A. Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP): This action is not the priority in the context of the client's current clinical status, particularly with the risk of placental abruption and severe bleeding. Fetal monitoring via scalp electrode and IUCP is typically reserved for stable clients, and invasive monitoring should be avoided in a potentially unstable situation.

B. Obtain serial H&H and clotting studies: The client is presenting with significant vaginal bleeding, low hemoglobin (8.1 g/dL at 0930, decreased to 7.5 g/dL at 1005), and low hematocrit levels (24% at 0930, dropping to 21% at 1005). Serial hemoglobin and hematocrit levels will help monitor ongoing blood loss and guide decisions regarding further interventions, such as transfusion. Clotting studies, including the prothrombin time and PTT, are necessary to assess the client's coagulation status and potential for disseminated intravascular coagulation (DIC), which can be associated with placental abruption or severe bleeding.

C. Administer misoprostol 600 mg rectally: Misoprostol is used to manage postpartum hemorrhage or to induce labor, but it is not indicated in the acute management of this client's condition. The client is 38 weeks gestation and presenting with signs of potential placental abruption, not requiring the use of misoprostol at this time.

D. Place the client in a supine position: The client should not be placed in a supine position, as this may exacerbate hypotension due to the supine hypotension syndrome, particularly if the uterus is compressing the inferior vena cava. The client would benefit more from positioning that promotes circulation, such as lying on the left side.

E. Prepare to transfuse 2 units of packed RBCs: The client is showing signs of hypovolemic shock with progressively declining blood pressure (from 95/62 mm Hg to 85/48 mm Hg), elevated heart rate (from 104/min to 128/min), and worsening hematocrit and hemoglobin. Blood transfusion is likely necessary to restore circulating volume, improve oxygen delivery, and address the ongoing blood loss.


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Related Questions

Correct Answer is []

Explanation

Potential Condition: Kawasaki Disease

Kawasaki disease is a systemic vasculitis that primarily affects children under the age of 5 but can occur in older children. It presents with prolonged fever (lasting more than 5 days), conjunctival injection (red eyes without exudate), mucosal inflammation (strawberry tongue, red lips), maculopapular rash, and extremity changes (edema and peeling skin on hands and feet). Elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), high WBC count, and thrombocytosis (elevated platelets) are consistent with Kawasaki disease. If untreated, it can lead to coronary artery aneurysms.

Actions to Take:

Plan to administer high dose of aspirin:

High-dose aspirin is given to reduce inflammation and prevent thrombosis in coronary arteries, as Kawasaki disease increases the risk of coronary artery aneurysms.

Assess for neurological changes:

Neurological changes, such as irritability, can indicate aseptic meningitis or other central nervous system involvement, which can occur in Kawasaki disease.

Parameters to Monitor:

Daily weights:

Monitoring daily weights is essential to assess for fluid retention or overload, as Kawasaki disease can cause myocarditis and cardiac dysfunction.

Reports of chest pain or pressure:

Monitoring for chest pain or pressure is crucial to detect early signs of myocardial ischemia or coronary artery involvement, which are potential complications of Kawasaki disease.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Assessment Findings Consistent with Mastitis or Endometritis

  1. Painful, tender breast: Mastitis
    • Mastitis often presents with breast pain, tenderness, and redness.
  2. Foul-smelling lochia: Endometritis
    • Endometritis can cause foul-smelling vaginal discharge or lochia.
  3. Temperature: Both Mastitis and Endometritis
    • Both conditions can cause fever.
  4. Chills: Both Mastitis and Endometritis
    • Chills can be a symptom of both mastitis and endometritis

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