QUESTION: "Soon after a pregnant client arrives at the birthing center, the nurse observes moderately increased bloody vaginal discharge (show). Which of the following would the nurse expect to do next?"
CHOICES
( X ) a.) Check fetal descent by performing Leopold's maneuvers.
( O ) b.) Perform a vaginal examination to determine cervical dilation.
( X ) c.) Check for rupture of the membranes with a sterile speculum.
( X ) d.) Notify the physician of possible abruption of the placenta.
RATIONALE: Increased bloody show normally occurs when cervical dilation increases. Thus, the nurse would perform a vaginal examination to determine cervical dilation. Leopold's maneuvers help to determine fetal positioning, not fetal descent. Rupture of the fetal membranes results in the escape of amniotic fluid, not bloody show. Abruptio placenta is usually accompanied by boardlike abdominal pain and bleeding, which is frequently concealed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
