A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?

Rationale:

A. Apply direct pressure to the wound with thick dressing material: Direct pressure is the first-line intervention for controlling active external bleeding. Applying firm pressure with thick, sterile dressing helps tamponade the bleeding vessel and minimizes blood loss while awaiting further treatment.

B. Apply a transparent dressing to the wound: Transparent dressings are used for minor wounds or IV sites, not for managing active bleeding. They do not provide the necessary compression to control hemorrhage from a deep or penetrating injury.

C. Irrigate the wound with sterile water: Wound irrigation is appropriate for cleaning minor wounds or after bleeding is controlled. Irrigating during active bleeding can delay hemostasis and increase blood loss.

D. Tie a tourniquet around the leg distal to the wound: A tourniquet, if necessary, must be placed proximal not distal to the bleeding site to effectively restrict arterial flow. Distal placement worsens bleeding and can compromise tissue perfusion unnecessarily.

Rationale:

A. A client who reports a sudden onset of dizziness when sitting up: Although concerning, dizziness on position change may indicate orthostatic hypotension and is not immediately life-threatening. This client requires monitoring but is not the top priority based on airway or circulatory compromise.

B. A client who has new onset urticaria and angioedema: New urticaria and angioedema suggest a potential anaphylactic reaction, which can quickly progress to airway obstruction. This is a life-threatening emergency requiring immediate intervention to secure the airway and administer epinephrine.

C. A client who has numerous rectal polyps and blood-tinged stools: This condition could indicate a colorectal condition such as polyposis or malignancy, but it is not acutely life-threatening. The client needs evaluation, but not before those with airway or circulatory risks.

D. A client who has a subluxation of the fifth digit on the left foot: A subluxation is a partial dislocation, which can be painful but does not involve vital organ systems. This musculoskeletal issue is stable and can be addressed after more urgent needs are met.