A nurse is caring for a 30-year-old gravida 4, para 3 client at 30 weeks gestation diagnosed with complete placenta previa who presents to the emergency department with bright red vaginal bleeding. Her vital signs are: BP 100/60 mmHg, HR 110 bpm, RR 22/min, temperature 98.4°F. Fetal heart rate is 130 bpm with moderate variability. The client reports feeling dizzy but denies abdominal pain or contractions. Ultrasound confirms complete placenta previa with the placenta completely covering the cervical os. Which nursing intervention should be the priority?
A 28-year-old gravida 2, para 1 client at 32 weeks gestation arrives at the emergency department reporting sudden onset of bright red, painless vaginal bleeding that started 2 hours ago. Her vital signs are: BP 110/70 mmHg, HR 95 bpm, RR 20/min, temperature 98.6°F. Fetal heart rate is 140 bpm with minimal variability. The client reports feeling lightheaded but denies abdominal pain or contractions. Ultrasound confirms complete placenta previa with the placenta completely covering the cervical os.
1Maintain complete bed rest with bathroom privileges only and avoid all vaginal examinations✓ 정답
2Prepare the client immediately for emergency cesarean delivery
3Administer IV fluids and obtain blood for type and crossmatch
4Position the client in Trendelenburg position to reduce bleeding
해설
Complete bed rest with bathroom privileges and avoiding vaginal exams is the priority to prevent further hemorrhage in placenta previa. Other interventions like preparing for delivery or administering IV fluids are important but secondary to preventing exacerbation of bleeding.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a stable patient with complete placenta previa experiencing active but non-life-threatening bleeding. The core theme is conservative management versus immediate delivery. In placenta previa, the placenta implants over the cervical os. Bleeding occurs as the lower uterine segment thins and stretches in the third trimester, disrupting placental attachment. The priority is to Key Point!prevent further bleeding and prolong the pregnancy to improve fetal lung maturity, as long as the mother and fetus are stable.
Answer Rationale: The correct answer is Maintain complete bed rest with bathroom privileges only and avoid all vaginal examinations. The patient's vital signs (BP 100/60 mmHg, HR 110 bpm) indicate mild tachycardia but stable maternal hemodynamics. The fetal heart rate is reassuring. This scenario describes a stable, non-laboring patient. Key Point! The single most critical action to prevent catastrophic hemorrhage in placenta previa is to avoid any manipulation or examination of the cervical os, including digital vaginal exams, which can directly traumatize the placenta and cause massive, immediate bleeding. Bed rest reduces physical exertion and pressure on the placenta.
Distractor Analysis:
Watch out for confusion!Prepare the client immediately for emergency cesarean delivery is incorrect. While cesarean delivery is the definitive treatment for placenta previa, it is not the immediate priority for a stable patient at 30-32 weeks. The goal is to delay delivery until at least 36-37 weeks if possible to reduce neonatal complications. Emergency delivery is reserved for unstable maternal hemodynamics, fetal distress, or life-threatening hemorrhage.
Watch out for confusion!Administer IV fluids and obtain blood for type and crossmatch is an important supportive measure but is secondary to the immediate action of preventing further bleeding. Starting an IV and getting blood ready are part of preparation, but they do not address the primary cause of ongoing risk.
Watch out for confusion!Position the client in Trendelenburg position to reduce bleeding is incorrect and potentially harmful. The Trendelenburg position (head down) is not recommended for antepartum bleeding as it does not effectively reduce uterine bleeding and can impair maternal respiratory function and increase intracranial pressure. The appropriate position is left lateral recumbent to improve placental perfusion and maternal comfort.
Related Concepts: Management of placenta previa is guided by the "expectant management" protocol for stable patients, which includes hospitalization, bed rest, avoidance of intercourse/douching/vaginal exams, close monitoring, and administration of corticosteroids to accelerate fetal lung maturity. The transition to active management (delivery) occurs with labor, recurrent or heavy bleeding, or fetal maturity.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in Labor & Delivery triage. A 30-week pregnant patient, Ms. Jones, arrives with bright red vaginal bleeding. She is anxious but alert. Her pads are moderately saturated. Fetal monitor shows a reassuring pattern.
Nursing Intervention Strategy:
1Immediate Safety & AssessmentPlace the patient on left lateral recumbent position. Apply external fetal and contraction monitors. DO NOT PERFORM A DIGITAL VAGINAL EXAM. Assess bleeding (pad count, saturation). Obtain vital signs frequently.
2Stabilization & MonitoringEstablish a large-bore IV line (e.g., 18-gauge) for potential fluid or blood administration. Obtain labs: CBC, coagulation panel, and type and crossmatch for 2-4 units of packed red blood cells. Monitor for signs of shock (increasing HR, decreasing BP, pallor, restlessness).
3Patient Education & SupportExplain the diagnosis and the critical reason for avoiding vaginal exams. Educate on complete pelvic rest (no intercourse, no douching). Provide emotional support and explain the plan for expectant management, including the potential need for hospitalization until delivery.
4Preparation for EscalationHave emergency delivery supplies and protocols ready. Administer corticosteroids (e.g., betamethasone) as ordered to promote fetal lung maturity if delivery is anticipated before 34 weeks.
Patient Safety and Precautions: The cardinal rule is Key Point!No vaginal exams in any patient with suspected placenta previa until it is definitively ruled out by ultrasound. Even a speculum exam should be performed with extreme caution by a physician. Always have IV access and blood products available. Continuously assess for concealed hemorrhage (pain, uterine tenderness, tightening) which can occur with placental abruption, a differential diagnosis.
Nursing Procedure & Medication FlowProcedure for Managing Antepartum Hemorrhage (Stable Patient):
1. ABCs (Airway, Breathing, Circulation) assessment.
2. Position: Left lateral tilt.
3. Monitoring: Continuous fetal heart rate and tocodynamometer.
4. IV Access: Establish large-bore IV. Infuse isotonic crystalloid (e.g., Lactated Ringer's) as ordered.
5. Labs: Stat CBC, type and screen/crossmatch.
6. Medications: Administer Rh(D) immune globulin (RhoGAM) if the patient is Rh-negative. Administer corticosteroids if between 24-34 weeks.
7. Documentation: Precise quantification of bleeding (pad counts, weights), vital signs, fetal status, and all interventions.
A Word from Your Senior Nurse
"Placenta previa can turn from a 'wait-and-see' to a 'stat C-section' scenario in minutes. Your sharp assessment skills are the first line of defense. Remember, that bright red, painless bleeding is the classic textbook sign. In practice, your calm demeanor and strict adherence to the 'no vaginal exam' rule are non-negotiable. You are protecting two lives by preventing an iatrogenic catastrophe. When you study, link the pathophysiology—the placenta blocking the exit—to the nursing action: don't poke the bear! This kind of critical thinking is what makes an excellent nurse and will shine through on your NCLEX."
Placenta Previa — A condition where the placenta implants over or near the internal cervical os. Classified as complete, partial, or marginal. Presents with painless, bright red vaginal bleeding in the second or third trimester.
Expectant Management — A conservative treatment approach for stable patients with placenta previa aimed at prolonging pregnancy to improve fetal maturity. Involves bed rest, close monitoring, and avoidance of interventions that could provoke bleeding.
Cesarean Delivery — The definitive and only safe mode of delivery for complete placenta previa, as vaginal delivery would cause catastrophic hemorrhage from the disrupted placenta during cervical dilation.
Corticosteroids — Medications (e.g., betamethasone) given to pregnant women at risk of preterm delivery between 24-34 weeks to accelerate fetal lung maturity and reduce the risk of neonatal respiratory distress syndrome (RDS).
Rh(D) Immune Globulin — A medication given to Rh-negative mothers to prevent isoimmunization, which can occur after fetomaternal hemorrhage (mixing of fetal and maternal blood), such as in cases of placental bleeding or trauma.