A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected.

Which assessment findings indicate the presence of concealed bleeding? Select all that apply.

Back pain

Heavy vaginal bleeding Increase in fundal height Hard, boardlike abdomen Persistent abdominal pain

Early deceleration on the fetal heart monitor

Rationale:

The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height; hard, boardlike abdomen; persistent abdominal pain; late decelerations in fetal heart rate; and decreasing baseline variability. Back pain, heavy vaginal bleeding, and early deceleration on the fetal heart monitor are not specific signs of concealed bleeding.

The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

Monitoring fetal status

Providing comfort measures

Changing the client's position frequently

Keeping the significant other informed of the progress of the labor

Rationale:

The priority in the plan of care should include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply.

Keep the room semi-dark. Initiate seizure precautions. Pad the side rails of the bed.

Avoid environmental stimulation.

Allow out-of-bed activity as tolerated.