The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital should cause the greatest concern?
1. "Blood pressure 110/68, pulse 90."
2. "Clear fluid is leaking from the vagina."
3. "Client is positioned in a left lateral tilt."
4. "Entrance wound present below the umbilicus."
4
Explanation:
1. These are normal vital signs, indicating a hemodynamically stable client.
2. Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term and would likely survive birth at this time.
3. Positioning the client in a lateral tilt position prevents vena cava syndrome.
4. Penetrating abdominal trauma has a 59% to 80% fetal injury rate. This fetus is at great risk for injury.
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