Author Question: As the triage nurse in the emergency room, you are reviewing results for the high- risk obstetric ... (Read 68 times)

nevelica · **on:** Jun 28, 2018

As the triage nurse in the emergency room, you are reviewing results for the high- risk obstetric client who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA).

You note that the Kleihauer-Betke test is positive. Based on this information, you anticipate that:

a. immediate birth is required.
b. the client should be transferred to the critical care unit for closer observation.
c. RhoGAM should be administered.
d. a tetanus shot should be administered.

Question 2

A female client presents to the emergency room complaining of lower abdominal cramping with scant bleeding of approximately 2 days' duration. This morning, the quality and location of the pain changed and she is now experiencing pain in her shoulder.

The client's last menstrual period was 28 days ago, but she reports that her cycle is variable, ranging from 21 to 45 days. Which clinical diagnosis does the nurse suspect?

a. Ectopic pregnancy
b. Appendicitis
c. Food poisoning
d. Gastroenteritis

InfiniteSteez · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
A positive Kleihauer-Betke test indicates that fetal bleeding is occurring in the maternal circulation. This is a serious complication and, because the client is a trauma victim, it is highly likely that she is experiencing an abruption. Therefore, the client should be delivered as quickly as possible to improve outcomes. There is no evidence to support that RhoGAM should be administered, because we have no information related to Rh factor and/or blood type. Similarly, a tetanus shot is not indicated at this time because there is no evidence of penetrating trauma. The client should be transferred to the obstetric area for birth, not the critical care unit setting.

Answer to Question 2

ANS: A
Even though the client's menstrual cycle has variability, all women are considered to be pregnant until proven otherwise. The client's presenting symptoms are typical for ectopic pregnancy, so the client should be monitored for the possible complication of rupture and shock.