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Zorluk: OrtaAnte/Intra/Postpartum and Newborn Care

An obstetric triage nurse is admitting a client in the late third trimester of pregnancy who reports a sudden onset of painless, bright red vaginal bleeding. Which intervention should the nurse prioritize?

  1. Apply an external electronic fetal monitor to assess the fetal heart rate.Cevap
  2. B
    Conduct a sterile digital pelvic examination to evaluate current cervical dilation.
  3. C
    Position the client flat on her back to facilitate an immediate abdominal assessment.
  4. D
    Assign the unlicensed assistive personnel to obtain the initial admission vital signs.

Cevap

The nurse should apply an external electronic fetal monitor to assess the fetal heart rate.
When a client presents with painless, bright red vaginal bleeding during the third trimester, placenta previa must be suspected. The nurse's immediate priority is to assess both maternal hemodynamics and fetal well-being. Applying an external electronic fetal monitor is a critical, non-invasive first action to determine if the fetus is becoming hypoxic due to the bleeding.

Adım Adım Çözüm

1
Identify the clinical significance of the client's symptoms.
Painless, bright red vaginal bleeding in the third trimester strongly suggests placenta previa.
Recognizing the pathology allows the nurse to anticipate severe risks, such as massive hemorrhage, and rule out contraindicated actions.
2
Determine the safest initial assessment approach.
Invasive procedures (like digital exams) are avoided; instead, external monitoring is utilized.
An external fetal monitor provides immediate, non-invasive data on fetal tolerance to the potential bleeding without risking placental trauma.
3
Evaluate the remaining options for safety and delegation principles.
Supine positioning and delegating initial vital signs to unlicensed personnel are identified as unsafe practices.
Supine positioning causes aortocaval compression, and an RN cannot delegate the initial assessment of a potentially unstable, hemorrhaging client.

Anahtar Kavram

Management of Suspected Placenta Previa
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Konular

Ante/Intra/Postpartum and Newborn Care

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