Difficulty: Medium
Average Score: 69%
Simulated
Passage / Scenario
A 32-year-old G3P1 client at 34 weeksÔÇÖ gestation presents with sudden-onset abdominal pain and dark red vaginal bleeding.Item 4 of 6
NursesÔÇÖ Notes
0900: A 32-year-old G3P1 client at 34 weeksÔÇÖ gestation presents with sudden-onset abdominal pain and dark red vaginal bleeding. She reports reduced fetal movement since this morning. The uterus is firm and tender to palpation. Fetal heart rate is 100 bpm with minimal variability. Her history includes mild preeclampsia and occasional tobacco use. BP is 144/92 mmHg, HR 104 bpm, T 98.7┬░F (37.0┬░C), and SpOÔéé is 98% on room air.
1000: A stat transabdominal ultrasound was performed. Findings include a retroplacental hematoma consistent with partial placental abruption. Fetal heart rate remains at 100 bpm with minimal variability. No evidence of placenta previa. Provider notified of results.
The nurse is anticipating the priority intervention for the client's acute condition. Choose the most likely options for the information missing from the sentence by selecting from the lists provided. The nurse anticipates that the priority intervention will be to................ in response to the risk for..................
Correct answer
D,E
Rationale
Emergency delivery is prioritized in placental abruption with fetal compromise (low heart rate, minimal variability) to prevent further fetal hypoxia.