The nurse is caring for a patient at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern?
1. "Blood pressure 110/68, pulse 90."
2. "Entrance wound present below the umbilicus."
3. "Patient is positioned in a left lateral tilt."
4. "Clear fluid is leaking from the vagina."
Correct Answer: 2
Rationale 1: These are normal vital signs, indicating a hemodynamically stable patient.
Rationale 2: Penetrating abdominal trauma has a 59–80% fetal injury rate. This fetus is at great risk for injury.
Rationale 3: Positioning the patient in a lateral tilt position prevents vena cava syndrome.
Rationale 4: 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.
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