The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced.
Question
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? – Q/A (Question and Answer)
Test Answer
Answer:
Monitor bleeding from IV sites. Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding.
Recource HESI Review Test-Maternity
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