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 C

Explanation

A CS4 who has had three prior lower transverse cesarean sections is at the highest risk for uterine rupture. The risk of uterine rupture increases with each subsequent cesarean section, and a history of three or more prior lower transverse cesarean sections is considered a significant risk factor for uterine rupture.

A. massage the woman's fundus. B. Begin an intravenous (IV) infusion of Ringer's lactate solution. C. Call the woman's primary health care provider. D. Assess the woman's vital signs.

Correct Answer is A

Explanation

The nurse's first action should be to massage the woman's fundus. A completely saturated perineal pad within 15 minutes after giving birth indicates excessive bleeding, which is also known as postpartum hemorrhage (PPH). Massaging the uterus (fundus) can help it to contract, reduce bleeding, and prevent further blood loss. Once the fundus has been massaged, the nurse should assess the woman's vital signs and continue to monitor her for signs of continued bleeding. If bleeding persists despite massage, the nurse should begin an intravenous (IV) infusion of Ringer's lactate solution and call the woman's primary healthcare provider.

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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

Which of the following patients is most at risk for uterine rupture?

Correct Answer is C

Explanation

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:

Correct Answer is A

Explanation

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