The nurse working in an Emergency Department admits a woman whose last menstrual period was seven weeks ago with acute severe lower right-sided abdominal pain with heavy menstrual bleeding
The client is very pale, and vital signs reveal a pulse of 122 and blood pressure of 86/52. The nurse's priority action while waiting for the physician is to: 1. Inform the client she has an ectopic pregnancy.
2. Place the client in Trendelenburg position.
3. Initiate an intravenous line.
4. Obtain a complete medical and surgical history.
2
Rationale: While the cause of the bleeding might be an ectopic pregnancy, it is not the nurse's role to diagnose the client, but placing her in Trendelenburg position might help to reverse shock symptoms. The nurse can prepare to initiate an IV, but it cannot be placed until the doctor orders it. A medical and surgical history may be obtained, but it is not the priority.
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