Health Promotion and Maintenance
58. A client who is gravida 2, para 1 is seen in an emergency department at 14 weeks' gestation with bright red vaginal bleeding and severe lower abdominal cramping. Which assessment finding is the most important observation at this time?
. Increased temperature.
. Increased pulse pressure.
. Increasing heart rate.
. Increased blood pressure.
Test-Taking Tip
Note that all the answers have "increased" as the first word. Since the client's symptoms are indicative of hemorrhage, the vital sign that increases with hemorrhage is heart rate (pulse).
Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because an increased temperature may be a sign of infection; however, this client's major symptom is bleeding, not infection. Answer 2 is incorrect because the client is at a high risk for excess blood loss. The pulse pressure decreases with hemorrhage. Answer 3 is correct because an increased pulse in the presence of visible bleeding indicates excessive blood loss. Answer 4 is incorrect because increased blood pressure at this stage of pregnancy would be a sign of a hydatidiform mole or chronic hypertension; decreased blood pressure is a sign of hemorrhage.