A client arrives in labor and delivery L&D who is gravida 2 para 1.
History and Physical0900:Client is at 36 weeks of gestation with no past medical problems. Has been experiencing
hypertension during pregnancy. No history of drug or alcohol abuse.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
- Currently vaginal bleeding has significantly increased and has soaked one 1 maxi pad within 40 minutes.
- Uterine contractions frequent, low amplitude.
- Client reports pain as 8 on pain scale from 0 to 10. Noted maxi pad soaked and additional blood noted in bed.
- Fetal heart tracing category 3.
- Blood pressure 86/64 mm Hg
- Heart rate 115/min
- Respiratory rate 26/min
The nurse is caring for a client who had a spontaneous abortion.
Admission Assessment
0900: Client is crying uncontrollably. They have been trying to get pregnant for 10 years and finally IVF worked. They have
had 2 miscarriages. Last menstrual period was 9 weeks ago. Awake alert, oriented x 3. Speech clear. Pupils equal and
reactive to light. Lung sounds clear, heart sounds regular, bowel sounds normoactive in all quadrants. Pedal pulses palpable
bilaterally. Grips equal. Minimal lochia rubra noted.
- History of spontaneous abortions
- Temperature
- Vaginal bleeding
- Abdominal pain
, A nurse is caring for a client who has placenta previa. Place the following actions in the correct order of nursing action.
1. Assess the client for OB history and signs of bleeding
2. Assess the fetal heart rate
3. Measure the blood loss to get and accurate amount
4. Obtain IV access
5. Prepare the client for delivery if indicated
A nurse is caring for several clients who have been diagnosed with placental abruption. Which of the following clients may
require an urgent cesarean delivery?
A client with a category III fetal heart tracing whoe vaginal delivery is not imminent
A nurse is providing medication teaching to a client who has a new prescription for a low molecular weight heparin
(LMWH). Which of the following statements should the nurse include in the teaching? (Select all that apply.)
1. "An electric razor is recommended for shaving"
2. "Any head injury should be evaluated by the emergency department"
3. "Seek care for cuts that won't stop bleeding"
4. "Use caution when clipping toenails"
A nurse is caring for a client who is experiencing a spontaneous abortion. Which of the following statements by the client
requires the nurse to intervene?
"I should wait 6 months before trying to get pregnant again."
History and Physical0900:Client is at 36 weeks of gestation with no past medical problems. Has been experiencing
hypertension during pregnancy. No history of drug or alcohol abuse.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
- Currently vaginal bleeding has significantly increased and has soaked one 1 maxi pad within 40 minutes.
- Uterine contractions frequent, low amplitude.
- Client reports pain as 8 on pain scale from 0 to 10. Noted maxi pad soaked and additional blood noted in bed.
- Fetal heart tracing category 3.
- Blood pressure 86/64 mm Hg
- Heart rate 115/min
- Respiratory rate 26/min
The nurse is caring for a client who had a spontaneous abortion.
Admission Assessment
0900: Client is crying uncontrollably. They have been trying to get pregnant for 10 years and finally IVF worked. They have
had 2 miscarriages. Last menstrual period was 9 weeks ago. Awake alert, oriented x 3. Speech clear. Pupils equal and
reactive to light. Lung sounds clear, heart sounds regular, bowel sounds normoactive in all quadrants. Pedal pulses palpable
bilaterally. Grips equal. Minimal lochia rubra noted.
- History of spontaneous abortions
- Temperature
- Vaginal bleeding
- Abdominal pain
, A nurse is caring for a client who has placenta previa. Place the following actions in the correct order of nursing action.
1. Assess the client for OB history and signs of bleeding
2. Assess the fetal heart rate
3. Measure the blood loss to get and accurate amount
4. Obtain IV access
5. Prepare the client for delivery if indicated
A nurse is caring for several clients who have been diagnosed with placental abruption. Which of the following clients may
require an urgent cesarean delivery?
A client with a category III fetal heart tracing whoe vaginal delivery is not imminent
A nurse is providing medication teaching to a client who has a new prescription for a low molecular weight heparin
(LMWH). Which of the following statements should the nurse include in the teaching? (Select all that apply.)
1. "An electric razor is recommended for shaving"
2. "Any head injury should be evaluated by the emergency department"
3. "Seek care for cuts that won't stop bleeding"
4. "Use caution when clipping toenails"
A nurse is caring for a client who is experiencing a spontaneous abortion. Which of the following statements by the client
requires the nurse to intervene?
"I should wait 6 months before trying to get pregnant again."
