A client at 36-weeks gestation is admitted to the labor and delivery unit with severe abdominal pain and bright red vaginal bleeding. The client's blood pressure is 160/110 mm Hg, and the fetal heart rate is 120 beats per minute. What condition should the nurse suspect?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Abruptio placentae. Abruptio placentae is a serious complication where the placenta detaches from the uterine wall before delivery. The clinical manifestations align with the client's presentation of severe abdominal pain, bright red vaginal bleeding, high blood pressure, and fetal distress indicated by a decreased heart rate. Option A) Placenta previa is characterized by painless, bright red bleeding in the third trimester, usually without abdominal pain. This condition is unlikely in the presence of severe abdominal pain. Option C) Preterm labor typically presents with regular contractions leading to cervical changes and is not associated with severe abdominal pain and high blood pressure. Option D) Uterine rupture is a rare but life-threatening event that may present with sudden, severe abdominal pain, but it is not typically associated with vaginal bleeding and high blood pressure as seen in this case. Educationally, understanding the differences between these conditions is crucial for nurses working in maternity care to provide prompt and appropriate interventions, ensuring the best outcomes for both the mother and the baby. This case highlights the importance of recognizing and responding to signs of abruptio placentae promptly to prevent complications such as maternal hemorrhage and fetal distress.

Correct Answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take first is to prepare for an emergency cesarean section (Option C). This is because the client's presentation with severe abdominal pain, bright red vaginal bleeding, elevated blood pressure, and fetal distress indicates a potentially life-threatening situation such as placental abruption or other obstetric emergency, necessitating immediate delivery to save the lives of both the mother and the baby. Assessing the fetal heart rate pattern (Option A) is important, but in this critical situation, time is of the essence, and immediate action to deliver the baby is crucial. Performing a vaginal examination (Option B) may exacerbate the bleeding and is not the priority in this case. Administering oxygen via face mask (Option D) is important in improving oxygenation, but it does not address the primary issue of ensuring the safety and well-being of both the mother and the baby in this emergency situation. This scenario highlights the importance of recognizing obstetric emergencies, prioritizing actions based on the urgency of the situation, and being prepared to act swiftly to ensure the best possible outcomes for both the mother and the baby in a labor and delivery setting.

Correct Answer: B

Rationale: In this scenario, the nurse should suspect preeclampsia. Preeclampsia is characterized by high blood pressure (≥140/90 mm Hg) and proteinuria after 20 weeks of gestation in a previously normotensive woman. The presence of severe headache, visual disturbances, and epigastric pain further supports this diagnosis. If left untreated, preeclampsia can progress to eclampsia, which involves seizures. Gestational hypertension refers to elevated blood pressure without proteinuria after 20 weeks of gestation. Chronic hypertension predates pregnancy or occurs before 20 weeks of gestation. Educationally, understanding the nuances between these conditions is vital for nurses working in maternity care. Recognizing the signs and symptoms of preeclampsia is crucial for timely intervention to prevent severe complications for both the mother and the baby. Nurses must be able to differentiate between these hypertensive disorders to provide appropriate care and ensure optimal outcomes for pregnant individuals.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to assess the client's blood pressure (Option A). This is crucial because the client's symptoms of feeling dizzy and lightheaded could indicate hypotension, which can be a serious concern during labor. Monitoring the blood pressure will provide vital information about the client's perfusion status and guide further interventions. Placing the client in a left lateral position (Option B) is generally beneficial to optimize fetal oxygenation but may not address the immediate concern of the client's dizziness. Administering oxygen via face mask (Option C) is important in cases of hypoxia, but assessing blood pressure takes precedence in this situation to identify the underlying cause of the client's symptoms. Notifying the healthcare provider (Option D) can be done after the initial assessment is completed and necessary interventions are initiated. Educationally, understanding the prioritization of nursing actions based on the client's condition is essential for providing safe and effective care. This question highlights the importance of quick and accurate assessment in responding to maternal and fetal well-being during labor and delivery, emphasizing the significance of timely interventions to address potential complications.

Correct Answer: A

Rationale: The correct action for the nurse to take first in this scenario is to perform a nonstress test (Option A). A nonstress test is a non-invasive way to assess fetal well-being by evaluating the fetal heart rate in response to fetal movement. In this case, the client's complaint of decreased fetal movement coupled with the clinical findings of cervical dilation, effacement, and fetal station indicate a need for immediate assessment of fetal well-being. Administering oxygen via face mask (Option B) may be indicated if there are signs of fetal distress, but assessing fetal well-being through a nonstress test should be the priority in this situation. Notifying the healthcare provider (Option C) can be important, but immediate assessment of fetal well-being should precede this step. Performing a biophysical profile (Option D) may provide more comprehensive information about fetal well-being, but it is a more time-consuming test compared to a nonstress test and may not be feasible as the first step when there are concerns about decreased fetal movement. In an educational context, understanding the rationale behind prioritizing actions in obstetric emergencies is crucial for nurses working in labor and delivery units. Recognizing the significance of prompt assessment and intervention in cases of decreased fetal movement can help prevent adverse outcomes for both the fetus and the mother. It is important for nurses to be able to prioritize actions based on the client's condition and current evidence-based guidelines to provide safe and effective care.