RN Nursing · High-Risk Pregnancy — Placenta Previa · Practice question
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitoring indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 80/40 mm Hg, heart rate 120/min, respiratory rate 24/min, and temperature 36.4° C (97.6" F). Which of the following is the priority nursing action?
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Insert a speculum to measure the amount of bleeding.
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✓
Initiate fluid replacement.
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Insert an indwelling urinary catheter.
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Witness the signature for informed consent for surgery.
Answer & explanation
Correct: Initiate fluid replacement.
The presentation of painless, bright red vaginal bleeding at 38 weeks with a stable fetal heart rate and no uterine contractions is classic for placenta previa. The client's vital signs indicate hypovolemic shock: blood pressure 80/40 mmHg and heart rate 120/min. The immediate priority is to address hemodynamic instability by initiating fluid replacement to restore circulating volume and maintain organ and uteroplacental perfusion. Using the ABCs and Maslow's hierarchy, circulation is the priority here. Inserting a speculum to measure bleeding is absolutely contraindicated in suspected placenta previa because it can disrupt the placenta and cause catastrophic hemorrhage. Inserting an indwelling urinary catheter is appropriate and will follow, but it is not the most urgent action when the client is in shock. Witnessing informed consent for surgery may become necessary, but establishing IV access and fluid resuscitation must occur first to stabilize the client's hemodynamic status. Initiating fluid replacement addresses the life-threatening shock and is therefore the priority nursing action in this scenario.
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