A nurse is caring for a newborn who is 4 hours old in the Neonatal Intensive Care Unit (NICU).

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Choice A rationale
Performing a fundal massage is not the appropriate action for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Fundal massage is typically used to stimulate contractions and reduce postpartum hemorrhage after the delivery of the placenta. However, in the case of placenta previa, where the placenta is covering the cervix, a fundal massage could potentially cause more harm and increase bleeding.
Choice B rationale
Assessing for abdominal tenderness is not the most immediate action for a nurse to take when a client with placenta previa is exhibiting a large amount of vaginal bleeding. While abdominal tenderness could indicate a complication such as placental abruption, the primary concern with placenta previa is the risk of severe bleeding that can endanger both the mother and the baby.
Choice C rationale
Obtaining serial hemoglobin and hematocrit is the correct action in this situation. These laboratory tests are important for monitoring the client’s blood loss and determining the need for a possible blood transfusion. With a large amount of vaginal bleeding, the client is at risk for anemia and hypovolemic shock, so close monitoring of blood levels is crucial.

Choice C rationale

Monitoring vital signs closely is an important part of care for any client, but it is not the most specific action a nurse should take for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Vital sign changes could indicate worsening of the client’s condition, but these changes often occur late in the progression of blood loss. Therefore, while important, it is not the most immediate action to take.

Choice A rationale
Hypotension is a known adverse effect of epidural analgesia. The epidural can block sympathetic nerve fibers, which can lead to vasodilation and a drop in blood pressure.
Choice B rationale
A maternal temperature of 37.4 C (99.4 F) is within the normal range and is not typically a cause for concern. While epidural analgesia can potentially cause a slight increase in body temperature, a significant fever is not a common side effect.
Choice C rationale

Polyuria, or excessive urination, is not a typical side effect of epidural analgesia. While the epidural can affect nerve signals to the bladder, it does not typically cause the kidneys to produce more urine.
Choice D rationale
A fetal heart rate of 152/min is within the normal range for a fetus (110-160 beats per minute). While epidural analgesia can potentially affect the baby’s heart rate if it causes significant maternal hypotension, a heart rate of 152/min is not indicative of a problem. CytomegalovirusCytomegalovirus Explore