The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is:
Monitor uterine contractions.
Assess fetal heart rate (FHR) and maternal vital signs.
Perform a venipuncture for hemoglobin and hematocrit levels.
Place clean disposable pads to collect any drainage.
The Correct Answer is B
Choice A) Monitor uterine contractions is incorrect because this is not the most urgent intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Uterine contractions can indicate labor or placental abruption, which are possible causes of bleeding in late pregnancy. However, they are not the only or the most reliable indicators of these conditions, as some women may have painless bleeding or contractions without bleeding. Moreover, monitoring uterine contractions does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Choice B) Assess fetal heart rate (FHR) and maternal vital signs is correct because this is the most important and essential intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Bleeding in late pregnancy can be caused by various conditions, such as placenta previa, placental abruption, uterine rupture, or vasa previa, which can compromise the blood supply and oxygen delivery to the mother and the fetus. Assessing FHR and maternal vital signs can help to determine the severity and cause of the bleeding, as well as guide further
interventions such as fluid resuscitation, oxygen therapy, blood transfusion, or emergency delivery. The normal FHR range for a fetus is 110 to 160 beats per minute, and it may vary with fetal activity or maternal position. The normal maternal vital signs are: blood pressure 120/80 mm Hg or lower, heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, and temperature 36.5°C to 37.5°C (97.7°F to 99.5°F). Any deviation from these ranges may indicate hypoxia, hypovolemia, shock, infection, or distress. Therefore, this intervention should be done as soon as possible for women who have bleeding in late pregnancy.
Choice c) Perform a venipuncture for hemoglobin and hematocrit levels is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Hemoglobin and hematocrit are blood tests that measure the amount of red blood cells and their percentage in the blood volume.
They can help to evaluate the extent of blood loss and the need for blood transfusion. However, they are not
immediate or accurate indicators of bleeding in late pregnancy, as they may take time to reflect the changes in blood volume or be affected by other factors such as hydration or hemodilution. Moreover, performing a venipuncture does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion.
Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Choice d) Place clean disposable pads to collect any drainage is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Placing clean disposable pads can help to keep the perineal area clean and dry, as well as to estimate the amount and type of bleeding. However, it does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Moreover, it does not provide any information about the cause or severity of the bleeding, as it may be affected by factors such as gravity or pooling. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice a) Have the parent fold the infant's arms across the chest is incorrect because this is not a helpful way to calm a preterm infant. Folding the arms across the chest can restrict the infant's breathing and movement, and may increase their stress and discomfort. Preterm infants need gentle and supportive touch, not restraint or pressure.
Choice b) Encourage the parent to place the infant back in the warmer is incorrect because this is not a necessary or beneficial action for a preterm infant who is showing signs of overstimulation. Placing the infant back in the warmer can interrupt the bonding and attachment process between the parent and the infant, and may make the infant feel more isolated and insecure. Preterm infants need close and frequent contact with their parents, not separation or detachment.
Choice c) Encourage the parent to do kangaroo care is correct because this is an effective and evidence-based method of soothing and stabilizing a preterm infant who is experiencing overstimulation. Kangaroo care is a technique where the parent holds the infant skin-to-skin on their chest, providing warmth, comfort, and security. Kangaroo care can reduce the infant's stress hormones, lower their heart rate and blood pressure, improve their oxygenation and breathing, enhance their growth and development, and strengthen their bond with their parent.
Choice d) Cover the infant with a warm bed blanket is incorrect because this is not a sufficient or optimal way to comfort a preterm infant who is displaying signs of overstimulation. Covering the infant with a warm bed blanket can provide some warmth and protection, but it does not offer the same benefits as kangaroo care. A warm bed blanket cannot mimic the parent's heartbeat, voice, smell, and movement, which are essential for the infant's emotional and physiological well-being. Preterm infants need human touch and interaction, not just physical warmth.
Correct Answer is A
Explanation
Choice a) Headaches is correct because this is a condition that can indicate a serious problem in the postpartum period and may require careful medical assessment. Headaches are common in the first few weeks after giving birth, but they can also be a sign of complications such as preeclampsia, eclampsia, cerebral venous thrombosis, meningitis, or aneurysm. Preeclampsia and eclampsia are conditions that cause high blood pressure, proteinuria, and seizures in pregnant or postpartum women. Cerebral venous thrombosis is a blood clot in the brain that can cause stroke-like symptoms. Meningitis is an infection of the membranes that cover the brain and spinal cord. Aneurysm is a bulge or rupture in a blood vessel that can cause bleeding in the brain. These conditions can be life-threatening and require immediate treatment. Therefore, women who experience severe, persistent, or unusual headaches in the postpartum period should seek medical attention as soon as possible.
Choice b) Varicosities of the legs is incorrect because this is not a condition that usually requires careful medical assessment in the postpartum period. Varicosities are enlarged or swollen veins that appear blue or purple under the skin. They are common in pregnancy due to increased blood volume, hormonal changes, and pressure from the growing uterus. They usually improve after delivery, but may persist or worsen in some women. Varicosities are usually harmless and do not cause any symptoms, but they may cause cosmetic concerns, discomfort, itching, or bleeding. They can also increase the risk of superficial thrombophlebitis, which is inflammation of a vein near the skin surface. However, these complications are rare and mild, and can be managed with conservative measures such as compression stockings, elevation of the legs, exercise, and painkillers. Therefore, women who have varicosities of the legs in the postpartum period do not need to worry too much, unless they have signs of infection or deep vein thrombosis, which is a more serious condition that involves a blood clot in a deep vein that can travel to the lungs and cause pulmonary embolism.
Choice c) Carpal tunnel syndrome is incorrect because this is not a condition that typically requires careful medical assessment in the postpartum period. Carpal tunnel syndrome is a condition that causes numbness, tingling, pain, or weakness in the hand and wrist due to compression of the median nerve that runs through a narrow passage called the carpal tunnel. It can occur in pregnancy due to fluid retention, hormonal changes, or repetitive movements. It usually resolves after delivery, but may persist or recur in some women. Carpal tunnel syndrome is usually mild and does not cause any serious complications, but it may interfere with daily activities or quality of life. It can be treated with conservative measures such as splinting, icing, massage, stretching, or painkillers. In severe cases, surgery may be needed to release the pressure on the nerve. Therefore, women who have carpal tunnel syndrome in the postpartum period do not need to seek medical attention urgently, unless they have signs of nerve damage or infection.
Choice d) Periodic numbness and tingling of the fingers is incorrect because this is not a condition that generally requires careful medical assessment in the postpartum period. Periodic numbness and tingling of the fingers can be caused by various factors such as cold exposure, poor circulation, nerve compression, vitamin deficiency, or anxiety.
It can also occur in pregnancy due to fluid retention or hormonal changes. It usually goes away after delivery, but may linger or come back in some women. Periodic numbness and tingling of the fingers is usually harmless and does not indicate any serious problem, but it may cause discomfort or annoyance. It can be relieved with simple measures such as warming up, moving around, shaking out the hands, taking supplements, or relaxing. Therefore, women who experience periodic numbness and tingling of the fingers in the postpartum period do not need to worry too much, unless they have signs of infection or neurological disorder.

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