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    ATI Maternity proctored quiz

    The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to:

    Explanation & Rationale

    Choice A rationaleMonitoring uterine contractions is important during labor, but in the context of late pregnancy bleeding, the immediate priority is to assess the well-being of both the mother and the fetus. Contractions may or may not be present at this stage.Choice B rationalePlacing clean disposable pads is a reasonable action to manage bleeding and assess its characteristics. However, it does not address the immediate need to evaluate the maternal and fetal status, which is critical in a bleeding episode during late pregnancy.Choice C rationaleAssessing fetal heart rate (FHR) is crucial to determine fetal well-being in the presence of bleeding. Maternal vital signs (blood pressure, heart rate, respiration) are equally important to evaluate the mother's hemodynamic stability. Bleeding in late pregnancy can compromise both maternal and fetal oxygenation and perfusion, making this assessment the highest priority. Normal maternal heart rate is typically 60-100 beats per minute, and normal maternal blood pressure is typically 90/60 mmHg to 120/80 mmHg. The normal fetal heart rate range is 110-160 beats per minute.Choice D rationalePerforming a venipuncture for hemoglobin and hematocrit levels will provide information about the extent of blood loss and the mother's oxygen-carrying capacity. While this is an important assessment, it is not the immediate priority compared to evaluating the fetal heart rate and maternal vital signs, which provide real-time information about their current status. Normal hemoglobin for pregnant women typically ranges from 10.5 to 14 g/dL in the first and third trimesters and slightly lower in the second trimester due to hemodilution. Normal hematocrit for pregnant women typically ranges from 32% to 42%.

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