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.
Core Nursing Explanation
This question tests the priority nursing action for a stable patient diagnosed with complete placenta previa. The core principle is avoiding any intervention that could disrupt the placenta and cause massive, life-threatening hemorrhage.
Key Concept AnalysisPlacenta previa occurs when the placenta implants over or near the internal cervical os. In complete placenta previa, the placenta completely covers the os. The hallmark symptom is painless, bright red vaginal bleeding in the third trimester, as the lower uterine segment thins and the cervix begins to efface/dilate, causing placental separation. The primary danger is Key Point!exsanguinating hemorrhage for the mother and compromised fetal oxygenation.
Answer Rationale
The patient is currently stable (normal vital signs, reassuring fetal heart rate). The immediate goal is conservative management to prolong the pregnancy for fetal lung maturity, while preventing any action that could worsen bleeding. Therefore, the priority is Key Point!Maintain strict bed rest and monitor maternal and fetal status. This includes:
* Bed rest: Minimizes pressure on the placenta and reduces the risk of further separation.
* Continuous monitoring: Frequent assessment of maternal vital signs (for signs of hypovolemia), vaginal bleeding (pad count), and continuous electronic fetal monitoring (for signs of fetal distress like late decelerations or bradycardia) are essential.
Distractor AnalysisWatch out for confusion! The incorrect options are dangerous interventions for placenta previa.
* ① Perform a sterile vaginal examination: This is absolutely contraindicated in suspected or confirmed placenta previa. Digital examination of the cervix can directly traumatize the placenta, leading to immediate, severe hemorrhage.
* ② Administer IV oxytocin: Oxytocin is a uterotonic used to induce labor or treat postpartum hemorrhage from uterine atony. In placenta previa, the bleeding source is the placenta itself, not a boggy uterus. Administering oxytocin could induce contractions, which would further shear the placenta and worsen bleeding.
* ③ Encourage ambulation: Activity and increased abdominal pressure can aggravate bleeding. The patient should be on bed rest, often in a lateral position to optimize placental perfusion.
Related Concepts
Management depends on maternal/fetal stability and gestational age. For an unstable mother or fetus, immediate cesarean section is the definitive treatment. Conservative management (as in this scenario) includes bed rest, possible corticosteroid administration to accelerate fetal lung maturity, and preparation for a scheduled c-section once the fetus is mature.
Concept Summary
* Placenta Previa: Painless, bright red bleeding in 3rd trimester. Placenta covers cervical os.
* Priority Nursing Action (Stable Patient): Strict bed rest, continuous monitoring (maternal VS, bleeding, fetal heart rate). NO vaginal exams.
* Definitive Treatment: Cesarean section.
* Key Differentiator from Abruptio Placentae: Previa = painless bleeding; Abruptio = painful, dark bleeding with a tense/tender uterus.
Side-by-Side Comparison!
Feature
Placenta Previa
Abruptio Placentae
Bleeding
Painless, bright red, often recurrent
Painful, dark (concealed or apparent), sudden onset
Uterus
Soft, non-tender
Firm, board-like, tender, hypertonic
Fetal Heart Rate
Often normal initially
Signs of distress (bradycardia, late decels) common
Risk Factors
Previous c-section, multiparity, advanced maternal age
Hypertension, trauma, cocaine use, smoking
Nursing Priority (Stable)
Bed rest, monitor, avoid vaginal exams
Lateral position, monitor for concealed hemorrhage & DIC, prepare for emergency delivery
Anatomy, Physiology & Pharmacology Points
* Anatomy: The lower uterine segment is poorly contractile. If the placenta is attached here, it cannot constrict bleeding vessels effectively after separation, leading to hemorrhage.
* Physiology: Bleeding is from maternal vessels. The fetus can become hypoxic if a significant portion of the placenta detaches.
* Pharmacology: Betamethasone or Dexamethasone may be given to promote fetal lung maturity (surfactant production) if delivery is anticipated between 24-34 weeks.
Memory Tips
* Previa = Painless & Placenta Precedes (comes before the baby over the cervix).
* Abruptio = Agonizing & Abdominal rigidity.
* Rule of "NO VE": In any painless 3rd trimester bleeding, assume placenta previa until proven otherwise and perform NO Vaginal Examination.
High-Frequency NCLEX Topics
NCLEX loves to test the critical contraindication of vaginal exams in placenta previa. You will also see questions on differentiating previa from abruptio based on presentation, and prioritizing actions in an obstetric hemorrhage scenario (remember ABCs and preparing for emergency delivery).
Watch Out for Question Variations!
* If the patient becomes unstable (BP drops 90/60, HR rises >120, fetal bradycardia): The priority shifts to Key Point!Initiating emergency protocols, starting large-bore IV lines, administering oxygen, and preparing for immediate cesarean section.
* If asked about patient education: Teach to report any bleeding immediately, avoid sexual intercourse, and adhere to bed rest.
* If asked about diagnostic confirmation: Transabdominal or transvaginal ultrasound is the gold standard for diagnosis.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a labor & delivery unit. A patient at 32 weeks gestation is admitted with a small amount of bright red bleeding. She is anxious but stable. An ultrasound confirms a complete placenta previa. The plan is for expectant management to gain more time for the baby.
Nursing Intervention Strategy
1Assessment* Maternal: Frequent vital signs (q1-2h initially), strict intake & output, pad count to quantify bleeding (weigh pads: 1 gram = 1 mL blood), assess for pain (should be absent), monitor for signs of shock (tachycardia, hypotension, pallor).
* Fetal: Continuous electronic fetal monitoring (EFM). Watch for variable decelerations (may indicate cord compression) or late decelerations (indicating uteroplacental insufficiency).
2Care & Environment* Enforce strict bed rest. Use bedside commode if allowed; no showers.
* Place a "NO VAGINAL EXAMS" sign prominently on the chart and at the bedside.
* Maintain IV access (one or two large-bore IVs) for emergency fluid or blood administration.
* Have cross-matched blood available at all times.
* Administer Rhogam if the mother is Rh-negative.
3Patient Education & Support* Explain the condition and the rationale for all restrictions clearly.
* Teach to report immediately: increased bleeding, contractions, abdominal pain, or decreased fetal movement.
* Provide emotional support; this is a very stressful time for the family.
Patient Safety and Precautions
* Key Point!Never, ever perform a digital cervical exam or insert anything into the vagina. This is the single most critical safety rule.
* If bleeding increases or the patient becomes unstable, do not wait for the physician to be physically present to start emergency protocols. Call a rapid response, administer O2 via non-rebreather mask, position in left lateral tilt, and increase IV fluids per protocol.
Nursing Procedure & Medication FlowProcedure: Managing a Patient with Placenta Previa
1Admit & StabilizePlace on bed rest, start IV (18-gauge or larger), draw labs (CBC, type & crossmatch, coagulation panel).
2Continuous MonitoringInitiate continuous EFM and maternal cardiac monitoring.
3Conservative ManagementMaintain bed rest, administer corticosteroids if ordered, provide anti-embolism stockings for DVT prophylaxis.
4Prepare for DeliveryPlan for a scheduled cesarean section, typically around 36-37 weeks if no complications arise earlier.
5Emergency ResponseIf massive hemorrhage occurs: Activate massive transfusion protocol, prepare OR, administer crystalloids/colloids, assist with emergency c-section.
Medication Alert: Tocolytics (like terbutaline or nifedipine) are controversial in placenta previa with bleeding. They may be used briefly to stop contractions and allow time for steroid administration, but they can mask signs of hypovolemic shock. Use with extreme caution and continuous monitoring.
A Word from Your Senior Nurse
"Placenta previa is one of those 'hands-off' diagnoses where your most important action is often what you don't do. That vaginal exam seems like a simple assessment, but in this case, it can be a lethal intervention. Your vigilance in monitoring for subtle changes—a slight increase in heart rate, a trickle of blood the patient might not mention—is what keeps both mother and baby safe. On the NCLEX, they are testing your judgment to avoid harm. In real life, you are the guardian enforcing that critical safety rule at the bedside."
Placenta Previa — A condition where the placenta implants over or near the internal cervical os, classified as marginal, partial, or complete. The primary symptom is painless, bright red vaginal bleeding in the second or third trimester.
Abruptio Placentae — The premature separation of a normally implanted placenta from the uterine wall before delivery. It presents with painful, dark vaginal bleeding (or concealed hemorrhage) and a tender, board-like uterus.
Cesarean Section — A surgical procedure to deliver a baby through incisions in the mother's abdomen and uterus. It is the definitive and safest method of delivery for complete placenta previa to avoid catastrophic hemorrhage during labor.
Expectant Management — A conservative approach in obstetrics where, in the absence of maternal or fetal distress, delivery is delayed to allow for further fetal maturation. Used in stable cases of placenta previa before 36-37 weeks.
Electronic Fetal Monitoring — The use of electronic devices to continuously record the fetal heart rate and uterine contractions. Essential for monitoring fetal well-being in high-risk pregnancies like placenta previa, detecting signs of distress such as decelerations or loss of variability.