A 32-year-old gravida 3, para 2 client at 34 weeks gestation is admitted to the labor and delivery unit with bright red vaginal bleeding. An ultrasound confirms complete placenta previa. The client is stable with vital signs: BP 110/70 mmHg, HR 88 bpm, respirations 18/min. The fetal heart rate shows a baseline of 140 bpm with good variability. What is the nurse's priority action?
1Perform a sterile vaginal examination to assess cervical dilation
2Administer IV oxytocin to control the bleeding
3Encourage ambulation to promote fetal descent
4Maintain strict bed rest and monitor maternal and fetal status✓ 정답
해설
With complete placenta previa, any cervical manipulation can cause massive hemorrhage. The priority is strict bed rest and continuous monitoring of maternal and fetal status to prevent further bleeding while allowing fetal maturation if possible.
Clinical Judgment
This question asks about the nurse's priority action when sudden bright red vaginal bleeding occurs in a patient with stable complete placenta previa. The key is to recognize the dangerous situation requiring Notify HCP!, while selecting the safest measure the nurse can independently perform as an immediate intervention. Since both maternal and fetal vital signs are stable (BP 110/70, FHR 140), an emergency cesarean section is not indicated. Therefore, the goal is conservative management to prolong the pregnancy as much as possible without causing further bleeding. Option 4 is the only safe action that aligns with this goal.
Memory Tip:
No Vaginal Exam, No Labor induction, Bedrest & Monitor! In placenta previa, Vaginal exam and Labor induction are contraindicated.
KR vs US:
In Korea, the basic management principles for placenta previa (contraindication of vaginal exam, conservative treatment) are the same. However, in the US NGN, there is a greater emphasis on the nurse's independent judgment and actions in a "stable" condition. Compared to the Korean exam, there is a tendency to evaluate the logical reasoning process of 'why other options are dangerous'.
Clinical Practice Guide
Management of a patient with stable placenta previa: 1) Absolutely no vaginal examination. 2) Continuous monitoring of vital signs, amount of bleeding, and fetal heart sounds. 3) Secure an IV line (in preparation for massive hemorrhage). 4) Prepare for blood type and crossmatch. 5) Consider administering steroids for fetal lung maturity (per physician's order).
Caution:
In SATA (Select All That Apply) questions asking about "nursing interventions to perform for a patient with placenta previa," "performing a vaginal examination" is never included. "Administering Oxytocin" or "transvaginal ultrasound" can also generally be risky. "Bed rest," "monitoring," and "securing an IV line" are likely correct answers.
Placenta Previa (전치태반) — A condition where the placenta abnormally implants in the lower part of the uterus, partially or completely covering the internal cervical os. Painless bright red vaginal bleeding is the characteristic symptom.
Complete Placenta Previa (완전 전치태반) — The placenta completely covers the internal cervical os, which is the most severe form of placenta previa. Any manipulation of the cervix, such as a vaginal examination, is absolutely contraindicated.
Conservative Management (보존적 관리) — A treatment approach that, when the mother and fetus are stable, aims to prevent further bleeding and prolong the pregnancy to promote fetal lung maturity. It includes bed rest, monitoring, and steroid administration if needed.
Bright Red Vaginal Bleeding (선홍색 질출혈) — A sign suggesting arterial bleeding, commonly seen in placenta previa or placental abruption. It indicates active bleeding and requires immediate evaluation.
Fetal Heart Rate Variability (태아심박수 변이성) — Subtle fluctuations in fetal heart rate. Good Variability is a reassuring sign that the fetal central nervous system is well-oxygenated and healthy.