QUESTION: "A 28-year-old multigravida at 32 weeks' gestation is admitted to the hospital because of vaginal bleeding. Which of the following actions would the nurse do first?"
CHOICES
( X ) a.) Perform a sterile vaginal examination.
( X ) b.) Administer a cleansing enema.
( X ) c.) Witness a consent for immediate cesarean delivery.
( O ) d.) Check fetal heart rate and maternal blood pressure.
RATIONALE: When a client is admitted with bleeding in the third trimester of pregnancy, the nurse should first assess fetal heart rate and maternal blood pressure to establish a baseline and evaluate fetal and maternal well-being. Vaginal examination is contraindicated for this client until the cause of the vaginal bleeding has been identified. For example, if the bleeding is due to abruptio placenta, a vaginal exam may cause further placental separation leading to excessive vaginal bleeding, thus placing the client at risk for hemorrhage. Any rectal manipulation, such as rectal examination or administration of an enema is contraindicated for this client until the cause of the vaginal bleeding has been identified. For example, if the bleeding is due to abruptio placenta, an enema may cause further placental dislodgment leading to excessive vaginal bleeding and subsequently possible hemorrhage. At this point, a cesarean delivery has not been planned, so witnessing a consent is not warranted. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
