A 35-year-old gravida 4, para 3 client at 36 weeks gestation is admitted with bright red vaginal bleeding and confirmed complete placenta previa. Which nursing action should be the priority?
1Prepare the client for immediate cesarean delivery
2Insert two large-bore IV catheters and obtain blood for type and crossmatch✓ 정답
3Position the client in Trendelenburg position to reduce bleeding
4Perform a sterile vaginal examination to assess cervical dilation
해설
With stable vital signs and fetal heart rate, priority is IV access and blood preparation for potential hemorrhage, not immediate delivery. Other options (Trendelenburg, vaginal exam) are contraindicated.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with complete placenta previa experiencing active bleeding. The core pathophysiology is that the placenta implants over the cervical os, blocking the exit for the fetus. Any cervical dilation or manipulation can shear the placenta from the uterine wall, causing catastrophic hemorrhage. The priority is maternal stabilization and preparation for potential massive blood loss, not immediate delivery if the mother and fetus are currently stable.
Answer Rationale: Key Point! The correct answer is ② Insert two large-bore IV catheters and obtain blood for type and crossmatch. This is the priority action because:
Maternal Stability First: The ABCs (Airway, Breathing, Circulation) of emergency care apply. Active bleeding threatens circulation. Establishing large-bore IV access is critical for rapid fluid and blood product resuscitation if bleeding worsens.
Proactive Preparation: Obtaining blood for type and crossmatch ensures that compatible blood is ready for transfusion at a moment's notice, which is a lifesaving measure in obstetric hemorrhage.
Non-Interference Principle: This action prepares for the worst while avoiding any intervention that could worsen the bleeding, which is the cardinal rule in managing placenta previa.
Distractor Analysis:
Watch out for confusion!
① Prepare for immediate cesarean delivery: While a cesarean delivery is the definitive treatment for complete placenta previa, it is not the immediate priority if the mother is hemodynamically stable and the fetus is not in distress. The priority is to stabilize the mother and prepare resources (IV access, blood) before proceeding to the OR. Jumping straight to preparation for surgery without securing IV access is putting the cart before the horse.
③ Position in Trendelenburg: This is contraindicated. The Trendelenburg position (head down, feet up) can increase pressure on the diaphragm, impair breathing, and does not effectively control uterine or vaginal bleeding. In obstetric emergencies, the recommended position is lateral tilt (left lateral position) to prevent supine hypotension.
④ Perform a sterile vaginal exam (SVE): This is absolutely contraindicated in suspected or confirmed placenta previa. Digital examination of the cervix can cause direct trauma to the placenta, leading to immediate, severe hemorrhage. Diagnosis is made via ultrasound, not physical exam.
Related Concepts: Management of placenta previa hinges on the principle of "hands off the cervix!" Care is focused on expectant management (if early and stable) or preparation for controlled delivery via cesarean section. Monitoring for signs of hypovolemic shock (tachycardia, hypotension, decreased urine output) and fetal distress is continuous.
Concept Summary
Concept
Key Takeaway
Placenta Previa
Placenta implants over or near cervical os. Presents with painless, bright red vaginal bleeding in 2nd/3rd trimester.
Priority Nursing Action
Stabilize mother first: Large-bore IV access, blood crossmatch, continuous monitoring (vitals, fetal heart rate).
Absolute Contraindication
NO vaginal exams, NO tampons, NO intercourse.
Definitive Treatment
Cesarean delivery for complete previa. Timing depends on maternal/fetal stability and gestational age.
Side-by-Side Comparison!
Condition
Placenta Previa
Abruptio Placentae (Placental Abruption)
Bleeding
Painless, bright red, often recurrent.
Painful, dark red (concealed or apparent), sudden onset.
Pain
Usually absent or mild.
Severe, constant uterine pain/tenderness.
Uterus
Soft, non-tender.
Hard, "woody," tender, may be tetanic.
Fetal Heart Rate
Often normal unless severe hemorrhage.
Signs of distress (late decelerations, bradycardia) are common.
Monitor for Couvelaire uterus and DIC (Disseminated Intravascular Coagulation).
Anatomy, Physiology & Pharmacology Points
Pathophysiology: In complete previa, the placenta completely covers the internal cervical os. As the lower uterine segment thins and dilates in late pregnancy, placental vessels tear, causing bleeding. The placenta cannot deliver oxygen if it is detached, so delivery is necessary once the fetus is mature or if bleeding is uncontrolled.
Drugs: Corticosteroids (e.g., betamethasone) may be given if delivery is anticipated between 24-34 weeks to promote fetal lung maturity. Tocolytics (to stop contractions) are controversial and used with extreme caution, as stopping contractions may not stop bleeding from previa.
Fluid Resuscitation: Initial fluid of choice is Isotonic crystalloid (e.g., Lactated Ringer's or Normal Saline). Blood products (packed red blood cells, fresh frozen plasma) are prepared for transfusion.
Memory Tips
Previa = Painless & Prohibited Exam (The 3 Ps).
ABRUPTion is PAINFUL.
Think "IVs and Blood FIRST" for any active obstetric hemorrhage scenario before any other procedure.
High-Frequency NCLEX Topics
NCLEX loves to test the priority action in obstetric emergencies. Placenta previa is a classic. Remember the sequence: Assess (vitals, fetal status) → Stabilize (IV, O2, position) → Prepare (blood, OR) → Treat (deliver). The "do nots" (no vaginal exam) are just as important as the "dos."
Watch Out for Question Variations!
If the question adds "fetal bradycardia" or "maternal hypotension," the priority might shift to immediate preparation for cesarean delivery while simultaneously initiating resuscitation.
They might ask about patient education for a woman diagnosed with previa at 28 weeks: Teach to report bleeding immediately, avoid intercourse/tampons, and come to hospital for any bleeding.
A question could contrast previa with vasa previa (fetal vessels presenting), which presents with bleeding and fetal bradycardia upon rupture of membranes.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in Labor & Delivery triage. Maria, 35, G4P3 at 36 weeks, arrives stating she just had a gush of bright red blood when she stood up. She denies pain. Her vital signs are: BP 118/74, HR 92, RR 18, SpO2 98%. The fetal heart rate (FHR) monitor shows a baseline of 140 with moderate variability and no decelerations.
Nursing Intervention Strategy:
Immediate Assessment & Positioning:
Apply the FHR and contraction monitors. Place the patient in a left lateral position to maximize placental perfusion and avoid supine hypotension.
Obtain a full set of vital signs and assess for signs of shock (pallor, cool skin, anxiety).
Priority Action - Secure Access & Blood:
Insert two large-bore (18-gauge or larger) IV catheters in antecubital veins.
Draw labs: Complete blood count (CBC), coagulation panel (PT/PTT/INR), and type and crossmatch for 4 units of packed red blood cells.
Initiate IV fluids (e.g., Lactated Ringer's) at a maintenance rate unless signs of active bleeding worsen, then bolus per protocol.
Continuous Monitoring & Communication:
Continuously monitor maternal vital signs (q5-15min) and FHR pattern.
Notify the obstetrician and blood bank immediately. Keep the patient NPO (nothing by mouth) in anticipation of possible surgery.
Provide emotional support and clear explanations to the anxious patient and family.
Patient Safety and Precautions:
NEVER attempt a vaginal or rectal exam. Place a "NO VAGINAL EXAMS" sign on the patient's door and chart.
Do not use the Trendelenburg position.
Monitor pad count to quantify bleeding.
Be vigilant for changes: A rising maternal heart rate is often the first sign of worsening hemorrhage before blood pressure drops.
Nursing Procedure & Medication FlowProcedure: Managing Active Bleeding in Placenta Previa
1. Safety First: Ensure patient is in a safe position (left lateral), apply monitors, administer oxygen via nasal cannula if indicated.
2. IV Access: Insert two large-bore IVs. Use an IV pump for precise control of fluid administration.
3. Lab Draw: Draw all necessary labs from the IV start before connecting fluids to avoid hemolysis and save the patient a needle stick.
4. Blood Administration Readiness: Verify the blood transfusion protocol is understood and that emergency release (O-negative) blood is available if crossmatched blood is not ready.
5. OR Preparation: Once the decision for cesarean is made, complete the preoperative checklist, administer preoperative antibiotics, and ensure informed consent is obtained.
Medication Alert:
- Magnesium Sulfate for neuroprotection may be ordered if delivery is imminent before 32 weeks. Know the signs of toxicity (loss of reflexes, respiratory depression) and have calcium gluconate at the bedside as the antidote.
- Oxytocin (Pitocin) or other uterotonics will be given after placental delivery to promote uterine contraction and control bleeding.
A Word from Your Senior Nurse
"Placenta previa is one of those situations where your knowledge directly saves lives. That moment when you see bright red blood and a history of previa, your brain should scream 'IVs and blood NOW, hands off!' It's about being proactive, not reactive. On the NCLEX, they're testing if you understand the 'why' behind the action. In real life, that understanding lets you move with calm, decisive speed. You're not just following an order; you're initiating the critical first steps that keep a mother stable long enough for the surgical team to safely deliver her baby. That's the power of nursing."
Placenta Previa — A condition where the placenta implants over or near the internal cervical os, leading to painless bright red vaginal bleeding in the second or third trimester.
Cesarean Delivery — A surgical procedure to deliver a baby through incisions in the mother's abdomen and uterus; the definitive mode of delivery for complete placenta previa.
Type and Crossmatch — A laboratory process to determine a patient's blood type and screen for antibodies, then match compatible donor blood for transfusion; critical preparation for potential hemorrhage.
Trendelenburg Position — A position where the patient's head is lowered and feet are raised. It is contraindicated in obstetric hemorrhage as it can compromise respiratory status and is ineffective for bleeding control.
Sterile Vaginal Examination — A physical examination of the vagina and cervix using a sterile glove. It is an absolute contraindication in suspected or confirmed placenta previa due to the risk of causing severe hemorrhage.