Difficulty: Medium
Average Score: 74%
Simulated
The nurse is caring for the client with a grade 3 placental abruption. Prioritize the prescribed interventions that the nurse should implement.
Correct answer
C,D,F,A,B,E
Rationale
Start oxygen at 2ÔÇö4 liters per nasal cannula is priority to maximize fetal oxygenation. Administer lactated RingerÔÇÖs at 200 mL/hr to treat hypovolemia, increase blood flow, and maximize oxygenation. Continuous external fetal monitoring should be performed to identify fetal distress early. Obtain serum blood draw for clotting disorders, specifically DIC. Administer 1 unit whole blood is next and will depend on the amount of blood loss. Prepare for cesarean delivery if fetal distress would be last because it would depend on the client and fetal status.