Difficulty: Medium
Average Score: 80%
Simulated
Passage / Scenario
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular Fetal Heart Rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4 C (97.6° F).A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4 C (97.6° F). Which of the following is the priority nursing action?
Correct answer
B
Rationale
Initiating IV access is the priority to administer fluids and blood products to maintain blood pressure and perfusion, addressing potential hypovolemic shock from severe bleeding likely due to placenta previa.