A nurse is about to measure the fundal height of a patient who is 22 weeks pregnant.
Where should the nurse anticipate feeling the fundus?

Choice A rationale

Maintain the patient on bed rest. This is a common nursing intervention for a patient who is experiencing an inevitable abortion. Bed rest can help reduce the risk of further complications, such as heavy bleeding. It can also provide the patient with a chance to rest and recover physically and emotionally.

Choice B rationale

Offer the option to view products of conception. This intervention may not be appropriate for all patients. While some patients may find it helpful to view the products of conception, others may find it distressing. It’s important to discuss this option with the patient and respect her wishes.

Choice C rationale

Administer oxygen via a nasal cannula. This intervention may not be necessary for all patients experiencing an inevitable abortion. While oxygen therapy can be used to treat hypoxia in patients with heavy bleeding, it’s not typically required unless the patient shows signs of hypoxia.

Choice D rationale

Instruct the patient to increase potassium-rich foods in the diet. This intervention is not typically part of the care plan for a patient experiencing an inevitable abortion. While a balanced diet is important for overall health, there’s no specific need to increase potassium-rich foods in the diet in this situation.

Choice A rationale

Inserting an indwelling urinary catheter is not the priority nursing action in this situation. While it may be necessary later in the care process, it is not the immediate concern when the client is experiencing a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. The priority is to stabilize the client and ensure the well-being of the fetus.

Choice B rationale

Witnessing the signature for informed consent for surgery is an important step before any surgical procedure. However, it is not the priority nursing action in this situation. The client’s condition could deteriorate rapidly due to the bleeding, and immediate medical interventions are necessary to stabilize the client and fetus.

Choice C rationale

Preparing the abdominal and perineal areas may be necessary if the client requires a surgical intervention. However, this is not the priority nursing action. The client is experiencing significant bleeding, and the priority is to stabilize the client’s condition.

Choice D rationale

Initiating IV access is the priority nursing action in this situation. The client is experiencing a large amount of painless, bright red vaginal bleeding, which could lead to hypovolemia and shock. IV access allows for the rapid administration of fluids and medications to stabilize the client’s condition.