A nurse is caring for a client at 32 weeks gestation diagnos… | 마이메르시 MyMerci
Maternal Newborn Health
문제

A nurse is caring for a client at 32 weeks gestation diagnosed with complete placenta previa who presents to the labor and delivery unit with bright red vaginal bleeding. Which nursing intervention should be the priority?

해설
In placenta previa with active bleeding, priority is to optimize maternal-fetal circulation and monitor fetal well-being. Left lateral positioning improves venous return, and continuous fetal monitoring detects compromise. Other options (vaginal exam, pain meds, ambulation) are contraindicated or lower priority as they may worsen bleeding or delay monitoring.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing intervention for a patient with complete placenta previa experiencing active, painless, bright red vaginal bleeding. The core pathophysiology is that the placenta implants over the cervical os, and any cervical dilation or manipulation can shear the placenta from the uterine wall, causing life-threatening hemorrhage for the mother and compromising fetal oxygenation. The priority is always Key Point! maternal and fetal stabilization, not diagnostic procedures that could worsen the situation.

Answer Rationale: Option ③ is correct because it combines two critical, stabilizing actions. Left lateral recumbent position relieves pressure on the maternal inferior vena cava, improving venous return, cardiac output, and uteroplacental perfusion. Continuous fetal monitoring (Non-stress test, NST) is essential to immediately assess fetal heart rate (FHR) for signs of compromise (e.g., late decelerations, tachycardia, bradycardia) due to potential blood loss and decreased placental perfusion. This intervention directly addresses the ABCs (Airway, Breathing, Circulation) for the fetus and optimizes maternal circulation.

Distractor Analysis:
Watch out for confusion! Option ①: Performing a sterile vaginal exam is absolutely contraindicated in suspected or confirmed placenta previa. Digital examination can cause catastrophic hemorrhage by directly disturbing the placenta. Diagnosis is confirmed by ultrasound, not physical exam.
Option ②: While patient comfort is important, administering pain medication is not the priority during an acute bleeding episode. The primary concern is hemodynamic stability. Furthermore, some analgesics/sedatives could depress the fetus, which is already at risk.
Option ④: Encouraging ambulation is contraindicated. Activity can increase bleeding. Management of placenta previa with active bleeding involves bed rest to minimize disturbance and reduce the risk of further placental separation.

Related Concepts: This scenario highlights the critical difference between placenta previa (painless, bright red bleeding) and abruptio placentae (painful, dark red bleeding with a rigid, tender uterus). Nursing priorities differ based on this assessment. The ultimate goal is to prolong the pregnancy to improve fetal lung maturity if possible, but immediate delivery via Cesarean section is indicated if bleeding is severe or the fetus is in distress. Concept Summary
ConceptKey Points
Placenta PreviaPlacenta implants over/next to cervical os. Presents with painless, bright red vaginal bleeding in 2nd/3rd trimester. Diagnosis by ultrasound. No vaginal exams.
Priority InterventionStabilize mother & fetus. Left lateral position, continuous fetal monitoring, IV access, assess vitals/bleeding, prepare for possible C-section.
Absolute ContraindicationDigital vaginal examination or any cervical manipulation.
Fetal MonitoringNon-stress test (NST) to check for fetal distress from hypoxia due to maternal blood loss.
Side-by-Side Comparison!
FeaturePlacenta PreviaAbruptio Placentae
BleedingPainless, bright red, visiblePainful, dark red or concealed, may not be visible
UterusSoft, non-tenderKey Point! Firm, rigid, board-like, very tender
Fetal Heart TonesOften normal unless severe hemorrhageFrequently show signs of distress (late decels, bradycardia)
Risk FactorsPrevious C-section, multiparity, advanced maternal ageHypertension, trauma, cocaine use, smoking
Nursing ActionNo vaginal exams. Monitor bleeding. Prepare for C-section.Assess for concealed bleeding (shock out of proportion to visible loss). Emergency delivery often needed.
Anatomy, Physiology & Pharmacology Points • Anatomy: In placenta previa, the placenta blocks the baby's exit. A vaginal exam can cause shearing and massive hemorrhage as the cervix begins to dilate. • Physiology: Left lateral position displaces the uterus off the inferior vena cava, preventing supine hypotensive syndrome and maximizing blood flow back to the heart and to the placenta. • Pharmacology: If delivery is necessary before 34 weeks, betamethasone (a corticosteroid) may be given to accelerate fetal lung maturity. Tocolytics (to stop labor) are generally not used in active bleeding from previa. Memory Tips • Previa = Painless (both start with 'P'). • NO VE for Previa: Never do a Vaginal Exam. • Left is Best: For any maternal compromise in pregnancy, think left lateral position first to improve circulation. High-Frequency NCLEX Topics Placenta previa is a classic NCLEX topic. You must know: 1) The hallmark sign (painless bright red bleeding), 2) The absolute contraindication (vaginal exam), and 3) The priority actions (positioning, monitoring, IV access). Expect questions that test your ability to prioritize safety over routine procedures. Watch Out for Question Variations! • Instead of asking for the priority intervention, a question might ask: "The nurse should question which prescribed order?" (Answer: A order for a sterile vaginal exam). • The scenario could change to abruptio placentae. The priority there is also monitoring and preparing for emergency delivery, but the presentation (pain, rigid uterus) is the key differentiator. • A question might test on the types of placenta previa (complete, partial, marginal) and their implications for delivery mode.

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in triage. Maria, 32 weeks pregnant, arrives stating, "I just started bleeding, and it's bright red." She denies pain. Her vital signs are BP 118/74, HR 92, RR 18. She is placed on a monitor, and the fetal heart rate (FHR) is 150s with minimal variability.

Nursing Intervention Strategy: 1. Immediate Assessment & Safety: Place her in left lateral position. Apply continuous external fetal and tocodynamic monitoring. Establish two large-bore IV lines with normal saline. Obtain vital signs frequently (every 5-15 min initially). Quantify bleeding (pad count). 2. Communication & Preparation: Notify the obstetrician immediately. Have the ultrasound machine brought to the bedside for confirmation—do not transport the patient unnecessarily. Prepare for potential emergency Cesarean section: ensure consent forms are ready, lab work (CBC, type & crossmatch) is drawn, and the operating room is alerted. 3. Ongoing Monitoring & Support: Continuously assess for signs of shock (tachycardia, hypotension, pallor) and fetal distress (late decelerations, bradycardia, loss of variability). Provide emotional support and clear explanations to the patient and family.

Patient Safety and Precautions: • Key Point! Under NO circumstances should anyone perform a digital cervical examination until placenta previa is ruled out by ultrasound. • Limit patient movement. Bed rest with bathroom privileges may be ordered if bleeding subsides. • Monitor for uterine activity. Contractions can worsen bleeding. Nursing Procedure & Medication Flow • Procedure: Continuous Fetal Monitoring Setup: Place the ultrasound transducer over the area of loudest FHR and secure it. Place the tocodynamometer on the uterine fundus. Document a 20-minute baseline strip. Interpret the tracing for reassuring signs (baseline 110-160, moderate variability, presence of accelerations) and non-reassuring signs (recurrent late or variable decelerations, bradycardia). • Medication: Anticipated Orders: - IV Fluids: Isotonic crystalloids (e.g., Lactated Ringer's) for volume expansion. - Rhogam: If the mother is Rh-negative, administer after any bleeding episode. - Betamethasone: May be ordered if delivery is imminent but can be delayed for 48 hours, to promote fetal lung maturity. - NOT Ordered: Tocolytics (like magnesium sulfate) are typically contraindicated in active bleeding as they can mask signs of shock. A Word from Your Senior Nurse "Placenta previa is one of those OB emergencies where your knowledge directly saves lives. Remember, your hands can do harm if you perform a routine check that becomes catastrophic. Your first instinct should always be to stabilize, monitor, and notify. In clinicals, if you see 'bright red bleeding' on an OB chart, your mental alarm bells should ring 'PLACENTA PREVIA' and 'NO VAGINAL EXAMS.' This isn't just for the test; it's a fundamental safety rule that you will carry with you to every labor and delivery unit."

핵심 개념

  • Placenta Previa — A condition where the placenta implants over or near the internal cervical os, leading to painless vaginal bleeding in the second or third trimester.
  • Left Lateral Recumbent Position — Positioning a pregnant patient on her left side to displace the uterus off the inferior vena cava, improving venous return, cardiac output, and uteroplacental blood flow.
  • Continuous Fetal Monitoring — The use of electronic equipment to continuously track the fetal heart rate and uterine contractions, essential for assessing fetal well-being during obstetric complications.
  • Abruptio Placentae — The premature separation of a normally implanted placenta from the uterine wall, characterized by painful vaginal bleeding and a tender, rigid uterus.
  • Supine Hypotensive Syndrome — A drop in maternal blood pressure caused by the gravid uterus compressing the inferior vena cava when the mother is in a supine position, alleviated by left lateral positioning.

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