What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?

Assessing fetal heart rate (FHR) and maternal vital signs

Performing a venipuncture for hemoglobin and hematocrit levels

Monitoring uterine contractions

Placing clean disposable pads to collect any drainage

Answer and Explanation

The Correct Answer is A

Assessing fetal heart rate (FHR) and maternal vital signs would be the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy. This is because fetal distress or maternal instability may require immediate medical intervention, such as delivery via emergency cesarean section or blood transfusions, respectively.

Therefore, assessing the FHR and maternal vital signs will help to determine the urgency of the situation and guide the next steps in the management of the patient. Once the patient's condition has stabilized, performing venipuncture for hemoglobin and hematocrit levels, monitoring uterine contractions, and placing clean disposable pads to collect any drainage can be done as appropriate.

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Correct Answer is D

Explanation

The question that the nurse would prioritize the least during the assessment is "Do you plan to have a vaginal or cesarean delivery?" This is because the priority at this point is to determine the urgency of the situation and assess the patient's current condition. The patient's delivery plan can be addressed later after the initial assessment is completed and the patient's stability has been established.

The other questions are all important in determining the cause and severity of the bleeding and the appropriate course of action. The question about the number of weeks is important to determine the gestational age and potential causes of bleeding, as some causes are more common in certain stages of pregnancy. The question about pain can help to determine the possible causes of bleeding and the patient's comfort level. The question about the last ultrasound is important to determine the location of the placenta and whether there are any abnormalities or potential complications.

A. "My provider will not perform any vaginal exams or vaginal ultrasounds. B. I still have the opportunity to labor and delivery my baby vaginally." C. 'Biophysical profiles will become important to monitor my baby. D. "At this point, I will not need betamethasone to mature my baby's lungs."

Correct Answer is B

Explanation

Placenta previa is a condition where the placenta implants low in the uterus, covering part or all of the cervix. This can cause bleeding and can be dangerous for both the mother and the baby. In cases of placenta previa, a cesarean delivery is necessary to avoid complications. Therefore, it is not safe for the patient to deliver vaginally.

Betamethasone is indicated in delivery anticipated before 34 weeks gestation. Vaginal exams may cause more bleeding in the event of placenta previa.

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What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient arrives at OB triage with a complaint of vaginal bleeding. The nurse would prioritize all of the following questions during the assessment except:

Correct Answer is D

Explanation

The nurse is providing education for a patient who has been newly diagnosed with a placenta previa at 37 weeks' gestation. The nurse understands that teaching has not been effective when the patient states:

Correct Answer is B

Explanation

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