A multigravida client is admitted to Labor and Delivery in active ...

[maychende]

A multigravida client is admitted to Labor and Delivery in active labor. Nursing diagnoses that might apply to the client with suspected abruptio placentae include: (Select all that apply.)
 
  1. Fluid Volume, risk for deficit related to hypovolemia.
  2. Tissue Perfusion, risk for altered related to blood loss.
  3. Anxiety related to concern for own safety.
  4. Knowledge deficit related to lack of information about inherited genetic defects.

Question 2

The client at 30 weeks' gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes:
 
  1. Limiting vaginal exams to only one per 24-hour period.
  2. Evaluating the fetal heart rate with an internal monitor.
  3. Monitoring for blood loss, pain, and uterine contractibility.
  4. Assessing blood pressure every two hours.

[ngr69]

Answer to Question 1

1, 2, 3
Rationale:
1. Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.
2. Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.
3. Maternal and perinatal fetal mortality are concerns due to blood loss and hypoxia.
4. Abruptio placentae is a premature separation of the placenta, not a genetic abnormality.

Answer to Question 2

3
Rationale:
1. Vaginal exams are contraindicated because the exam can stimulate bleeding.
2. Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal monitor.
3. Blood loss, pain, and uterine contractibility need to be assessed for patient comfort and safety.
4. Blood pressure measurements every two hours are unnecessary. They can be done on a routine basis or p.r.n.