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Original Question

FLAG A nurse on an antepartum unit is caring for a client. Which of the following nursing actions should the nurse plan to take? Exhibit 1 Exhibit 2 Exhibit 3 For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the client. Nurses’ Notes Potential Nursing Action Indicated Contraindicated 0900: Weigh perineal pads. O O Client reports a small amount of bright red blood in their underwear upon awakening. Client denies contractions or Assess cervical dilation. O O abdominal pain. Administer methotrexate. O External fetal monitor applied. OC Insert a large bore intravenous catheter. O 0930: Client passed large amount of bright red blood from vagina. Denies pain. Uterine tone soft and nontender to palpation. Contraction pattern: no contractions noted. Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No decelerations noted.

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