Which interventions should be immediately initiated when caring for a patient at 32 weeks' gestation who presents with a moderate amount of painless bright red vaginal bleeding?
Monitor vital signs.
Administer oxygen at 10L via non-rebreather face mask.
Perform a digital vaginal examination to assess cervical dilation.
Initiate intravenous (IV) Lactated Ringers for fluid replacement.
Assess client for incidence of domestic violence.
Correct Answer : A,D
Choice A rationale
Monitoring vital signs (blood pressure, heart rate, respiratory rate, temperature) is a crucial immediate intervention to assess the client's hemodynamic stability in the presence of vaginal bleeding. Bright red bleeding may indicate active bleeding that could compromise maternal and fetal well-being.
Choice B rationale
While oxygen administration might be considered if there are signs of fetal distress or maternal hypoxemia, applying oxygen at 10L via non-rebreather face mask is not the immediate first-line intervention for painless bright red vaginal bleeding at 32 weeks gestation without further assessment. The need for oxygen depends on the overall clinical picture.
Choice C rationale
A digital vaginal examination is contraindicated in the presence of unexplained vaginal bleeding in the third trimester, especially if placenta previa is suspected. Palpation of the placenta could cause severe hemorrhage. An ultrasound should be performed first to determine the cause of the bleeding.
Choice D rationale
Initiating intravenous (IV) Lactated Ringers for fluid replacement is an important immediate intervention to maintain intravascular volume and prevent hypovolemia, especially if the vaginal bleeding is significant. This helps to support maternal circulation and fetal perfusion.
Choice E rationale
While assessing for domestic violence is important for the overall well-being of the pregnant client, it is not an immediate intervention in the acute presentation of painless bright red vaginal bleeding at 32 weeks gestation. The immediate focus should be on assessing and managing the bleeding and maternal-fetal status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Persistent feelings of sadness that are pervasive and interfere with daily functioning, coupled with severe fatigue that goes beyond typical postpartum tiredness and a marked loss of interest in activities, including bonding and caring for the newborn, are key indicators of postpartum depression. These symptoms are more intense and prolonged than the emotional lability often seen in the postpartum period.
Choice B rationale
Feeling anxious about the baby's well-being is a common experience for many postpartum individuals as they adjust to parenthood. As long as this anxiety does not impair their ability to care for the baby effectively, it is more likely a component of normal postpartum adjustment rather than indicative of postpartum depression.
Choice C rationale
Experiencing occasional mood swings and irritability is typical during the postpartum period due to hormonal shifts, sleep deprivation, and the significant life changes associated with a new baby. These fluctuations are usually transient and less severe than the persistent sadness and loss of interest seen in postpartum depression.
Choice D rationale
Feeling overwhelmed and having difficulty sleeping are common challenges for new parents due to the demands of newborn care. While these symptoms can contribute to or exacerbate postpartum depression, they are not solely indicative of it unless accompanied by persistent sadness, severe fatigue, and a loss of interest in activities.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
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Blood pressure (Worsening):
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Elevated or worsening blood pressure can indicate the progression of hypertension or a related condition, such as preeclampsia. It’s a serious sign that needs immediate attention.
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Deep tendon reflexes (DTR) (Worsening):
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Increased or hyperactive deep tendon reflexes often indicate an abnormal neurological or medical condition, such as preeclampsia or nervous system distress. This worsening could signal a more severe condition, needing further evaluation.
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Vaginal exam (client denies pain) (Unrelated):
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The absence of pain during a vaginal exam may not be directly related to the client’s overall worsening or improving condition. It’s neutral in terms of contributing to any significant changes in the client’s condition.
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Decreased sensation in legs (Worsening):
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A worsening loss of sensation in the legs can suggest a neurological issue, such as nerve compression or even complications from a vascular condition. This condition is concerning, as it indicates progression and requires immediate investigation.
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Creatinine (Worsening):
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Elevated creatinine levels are a marker of kidney dysfunction or damage. If creatinine levels are worsening, it indicates a decline in kidney function, which could be a sign of renal failure or preeclampsia and needs urgent attention.
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