A 28-year-old gravida 1, para 0 client at 28 weeks gestation presents to the labor and delivery unit with sudden onset of bright red, painless vaginal bleeding. Vital signs are: BP 110/70 mmHg, HR 95 bpm, FHR 140 bpm with minimal variability. The client reports no abdominal pain or contractions. What is the priority nursing intervention?

Placenta previa requires strict bed rest to prevent further bleeding and hemorrhage. Vaginal exams or activities that increase intra-abdominal pressure are contraindicated.

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for a patient with Placenta previa presenting with painless third-trimester bleeding. The core pathophysiology involves an abnormally implanted placenta that covers or lies very near the internal cervical os. Any cervical dilation or manipulation can shear the placental vessels, causing massive, life-threatening hemorrhage for both mother and fetus. The priority is always preventing further bleeding and hemorrhage.

Answer Rationale: Key Point! The correct answer is Maintain strict bed rest with bathroom privileges only. This is the cornerstone of conservative management for a stable patient with placenta previa. The goal is to minimize any activity or pressure that could disturb the placenta and exacerbate bleeding. "Strict bed rest" means the patient remains in bed, and "bathroom privileges only" is a specific, common NCLEX phrasing indicating she may get up only to use the commode or bathroom, minimizing movement.

Distractor Analysis:
• Watch out for confusion! Option ①, Perform a sterile vaginal examination, is absolutely contraindicated in suspected or confirmed placenta previa. A digital exam can directly disrupt the placenta, triggering catastrophic hemorrhage. A sterile speculum exam may be performed by a physician in a controlled setting to rule out other causes, but it is never the nurse's independent action or priority.
• Option ②, Encourage ambulation, is incorrect. While ambulation is often encouraged in pregnancy, in this scenario, it increases intra-abdominal pressure and the risk of further placental separation and bleeding. Reducing anxiety is important but is addressed through communication and reassurance, not through activity that compromises safety.
• Option ④, Administer oxytocin, is incorrect. Oxytocin is a uterotonic used to stimulate contractions and control bleeding from uterine atony after delivery. In placenta previa, the bleeding source is the placenta itself, not a boggy uterus. Administering oxytocin could induce contractions, which may further separate the placenta and worsen bleeding.

Related Concepts: This scenario describes a stable, non-laboring patient. Nursing priorities include continuous maternal-fetal monitoring (vital signs, fetal heart rate), monitoring blood loss (pad counts, weighing pads), initiating IV access for possible fluid resuscitation or blood transfusion, and providing emotional support and education. The definitive treatment for placenta previa is cesarean delivery, but timing depends on gestational age and stability.

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in triage. A young pregnant patient arrives with sudden, painless bleeding. She is visibly frightened. Your initial rapid assessment (vital signs, asking about pain, checking FHR) points away from placental abruption (which is painful) and toward placenta previa.

Nursing Intervention Strategy: 1. Immediate Action & Assessment: Place the patient on bed rest immediately. Do not perform a vaginal exam. Apply external fetal and maternal monitors. Establish a large-bore IV line (e.g., 18-gauge) and draw labs (CBC, type and crossmatch). Quantify bleeding (pad count, save any clots/tissue). 2. Ongoing Monitoring & Care: Monitor for signs of hypovolemia (tachycardia, hypotension, pallor) and fetal distress (late decelerations, bradycardia, loss of variability). Administer IV fluids as ordered. Prepare for potential emergency cesarean section. 3. Patient Education & Support: Explain all procedures. Reassure the patient that monitoring is for her and her baby's safety. Educate on the importance of bed rest and reporting any increase in bleeding, pain, or contractions.

Patient Safety and Precautions: The cardinal rule is NO VAGINAL EXAMS. Also, avoid enemas, suppositories, or any activity that increases intra-abdominal pressure (straining, heavy lifting). Signs of worsening include increased bleeding, onset of pain or contractions, maternal hemodynamic instability, or non-reassuring fetal status.

Nursing Procedure & Medication Flow For a Stable Placenta Previa Patient: • Positioning: Left lateral recumbent position to optimize uteroplacental perfusion. • Monitoring: Continuous electronic fetal monitoring (EFM). Vital signs per protocol (e.g., q15min initially). • Medications: Watch out for confusion! Corticosteroids (e.g., betamethasone) may be given if delivery is imminent before 34 weeks to promote fetal lung maturity. Tocolytics (e.g., magnesium sulfate, nifedipine) might be used temporarily to stop contractions if they occur, but the primary management is bed rest, not pharmacologic suppression.

A Word from Your Senior Nurse "Placenta previa is a classic 'hands-off' condition. Your most critical nursing action is often what you don't do—you don't check that cervix. In clinical practice, you'll be the one to enforce bed rest, calmly explain why it's necessary to an anxious mom, and vigilantly watch for the subtle signs that this stable situation is becoming unstable. On the NCLEX, they love to test if you know the dangerous interventions to avoid. Always ask yourself: 'Will this action potentially cause more bleeding?' If the answer is yes, it's almost certainly wrong."