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    Pediatrics Proctored examQuestion 44
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    Pediatrics Proctored exam

    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?

    Explanation & Rationale

    A. Witnessing consent is important but does not address the immediate risk of maternal hypovolemia from active bleeding. B. Inserting a urinary catheter is useful for monitoring output but is not the first priority in a client with ongoing hemorrhage. C. Preparing the abdominal and perineal areas may be necessary for potential cesarean birth but does not immediately stabilize the client. D. Initiating IV access is the priority because the client is showing signs of early hypovolemic shock (tachycardia, low-normal blood pressure). Rapid IV access allows for fluid resuscitation and administration of blood products if needed, stabilizing both maternal and fetal status before other interventions.

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