QUESTION: "An emergency cesarean delivery is planned for a pregnant client who begins to experience excessive vaginal bleeding soon after admission. When developing this client's plan of care, which of the following would be the priority?"
CHOICES
( X ) a.) Shaving the abdomen and perineal area.
( X ) b.) Asking family members to wait in the waiting room.
( X ) c.) Assessing the status of the fetus.
( O ) d.) Ensuring availability of replacement blood.
RATIONALE: A cesarean delivery is considered major surgery. Thus, before any type of major surgery, the nurse should be certain that blood replacement therapy is available should any complications occur involving hemorrhage. The client is also at high risk for hypovolemic shock due to the excessive vaginal bleeding. Shaving the abdomen and perineal area may be required but this is not the priority at this time. Because the client is experiencing excessive vaginal bleeding, she is at greatest risk for hypovolemic shock necessitating blood replacement. Family members can be supportive and should be allowed to stay with the client if the client desires. Assessing the status of the fetus is important, but this can be accomplished once the availability of blood replacement has been confirmed. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
