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Author Question: A client with a total placenta previa presents to the hospital at 8 months, bleeding and is ... (Read 28 times)

lbcchick

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on: Jun 27, 2018
A client with a total placenta previa presents to the hospital at 8 months, bleeding and is delivered by cesarean section. Which potential nursing diagnosis is most pertinent during the initial postpartum period?
 
  a. Pain related to surgical incision
  b. Ineffective breastfeeding related to operative delivery
  c. Deficient fluid volume (hemorrhage) related to uterine atony
  d. Risk for injury related to the development of deep vein thrombosis

Question 2

You are caring for a woman in labor. Your assessment of the fetal heart rate reveals a heart rate of 145 with moderate variability. There are no signs of decelerations or accelerations. What is your priority action?
 
  a. Do nothing, since this is normal.
  b. Contact the physician immediately.
  c. Begin oxygen at 8 to 10 liters/minute.
  d. Change the maternal position immediately.


kristenb95

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Reply #1 on: Jun 27, 2018
Answer to Question 1

C
Deficient fluid volume (hemorrhage) related to uterine atony is an appropriate priority nursing diagnosis for this client. Deep vein thrombosis is not a realistic concern. A cesarean birth should not negatively impact breastfeeding. While pain related to surgical incision is an appropriate nursing diagnosis, it is not the pertinent one at this time, because the regional block is still in effect.

Answer to Question 2

A
The priority nursing action is to do nothing. A fetal heart rate of 145 with moderate variability is a normal situation. According to the classification system for fetal heart rate, this is a category 1 situation because the fetus shows no signs of decompensation.


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