A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
Determine fetal position by performing Leopold maneuvers.
Assess the fetal heart rate and client's contraction pattern
Confirm Rh and Coombs status for Rho(D) immunoglobulin administration
Perform sterile vaginal examination to determine dilatation
The Correct Answer is B
A. Determine fetal position by performing Leopold maneuvers:
Leopold maneuvers are used to determine the fetal position and presentation by palpating the mother's abdomen. While this information can be valuable, it's not the highest priority in a situation where there is significant vaginal bleeding.
B. Assess the fetal heart rate and client's contraction pattern:
This is the highest priority because it directly addresses the immediate concern. Monitoring the fetal heart rate and contraction pattern helps to assess the well-being of both the mother and the baby.
C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration:
While determining Rh status is important, it may not be the immediate priority in this situation. However, if there is a need for Rho(D) immunoglobulin administration, it should be addressed in a timely manner.
D. Perform sterile vaginal examination to determine dilatation:
Performing a sterile vaginal examination is an important aspect of assessing the progress of labor, but it may not be the highest priority when there is significant vaginal bleeding. The focus initially should be on assessing the fetal heart rate and contraction pattern.
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Related Questions
Correct Answer is C
Explanation
A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.
B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.
C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.
D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.
Correct Answer is D
Explanation
A. Describe genetic testing protocols: While genetic testing may be part of prenatal care, it's not the primary concern for a pregnant woman addicted to heroin. The focus should be on managing the addiction and promoting a healthy pregnancy.
B. Discontinue the methadone right away: Abruptly stopping methadone, or any opioid replacement therapy, can lead to withdrawal symptoms, which can be harmful to both the mother and the fetus. It's crucial for pregnant individuals on methadone to work closely with their healthcare provider to manage the transition.
C. Sign up for group therapy sessions: Group therapy can be a supportive intervention for individuals dealing with addiction, but it should be part of a comprehensive treatment plan that includes medical management.
D. Start a prenatal care plan as soon as possible: This is the most appropriate choice. Prenatal care is crucial for monitoring the health of both the mother and the baby. Starting early allows healthcare providers to address any potential issues and provide necessary support. This includes managing the mother's opioid addiction through medications like methadone, which can be administered under close medical supervision during pregnancy.
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