The perinatal nurse is providing care to a 17-year-old G2 TPAL 0010 patient at 32 weeks' gestation. An ultrasound examination confirms that she is experiencing an abruptio placentae. The patient's vital signs are as follows:
BP: 110/66 mm Hg, P: 92 beats/minute, R: 18 breaths/minute, fetal heart rate: 156 beats/minute. What assessment should the nurse include in this patient's plan of care as a priority?
A.
Hourly vital signs
B.
Intake and output every 8 hours
C.
Blood draw for complete blood count (CBC), prothrombin time (PT), and electrolytes
D.
Checks for perineal bleeding every 15 minutes
ANS: C
The nurse should review baseline and ongoing laboratory data, including complete blood count, clotting studies, serum electrolytes, and renal function tests. This baseline information is used to alert the care providers to changes in the patient's condition as additional laboratory tests are obtained.
Assessment of vital signs is dependent on the patient's condition. Intake and output may need to be monitored more frequently. Checks for bleeding every 15 minutes are not necessary.
You might also like to view...
Thickening or edema of the breast tissue called peau d'orange is most likely
a. indicative of renal disease. b. caused by plugged skin pores. c. indicative of a tumor that is obstructing lymphatic drainage. d. related to obesity or pregnancy.
A patient with a new ileostomy is preparing to go home. What should the patient be taught about changing his ileostomy?
A) Apply moisturizing lotion after cleaning the stoma. B) Apply a skin barrier to the peristomal skin prior to applying the pouch. C) Dispose of the clamp with each bag change. D) Cleanse the area surrounding the stoma with alcohol.
Which antihypertensive drug is considered safe for use during pregnancy or breastfeeding?
a. clonidine (Catapres) b. methyldopa (Aldomet) c. labetalol (Normodyne) d. carvedilol (Coreg)
The nurse is preparing a care plan for a person with late-stage Parkinson disease. The nurse should plan interventions to address which problem(s)? (Select all that apply.)
a. Dysphagia b. Hallucinations c. Immobility d. Insomnia e. Urinary incontinence