The priority nursing intervention when admitting a pregnant ...

[renzo156]

The priority nursing intervention when admitting a pregnant client who has experienced a bleeding episode in late pregnancy is to:
 
  a. monitor uterine contractions.
  b. assess fetal heart rate and maternal vital signs.
  c. place clean disposable pads to collect any drainage.
  d. perform a venipuncture for hemoglobin and hematocrit levels.

Question 2

A primigravida of 28 years of age is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following?
 
  a. She should be isolated from her family.
  b. This condition is caused by psychogenic factors.
  c. The treatment is similar to that for morning sickness.
  d. She should be assessed for signs of dehydration and starvation.

[janieazgirl]

Answer to Question 1

ANS: B
Assessment of the fetal heart rate (FHR) and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the client and fetus. Monitoring uterine contractions is important, but not the top priority. It is important to assess future bleeding, but the top priority is client and fetal well-being. The most important assessment is to check client and fetal well-being. The blood levels can be obtained later.

Answer to Question 2

ANS: D
The cause of hyperemesis gravidarum is unknown, but dehydration and starvation are the major complications. Emotional support is essential to the care of this client. She needs the opportunity to express how it feels to live with constant nausea. The cause is unknown. The first attempts to control the nausea are to treat it like morning sickness, but if treatment is not successful, further care is needed.