Health Promotion and Maintenance
100. A 27-year-old client, who is gravida 3, para 1, presents to a labor and delivery unit at 33 weeks' gestation. She tells a nurse that she woke up this morning in a pool of blood about the size of an orange, but she has no abdominal cramping or pain. The nurse's first action should be to:
. Assess the fetal heart tones.
. Check for cervical dilation.
. Check for firmness of the uterus.
. Obtain maternal vital signs.
Test-Taking Tip
Know the difference between placenta previa and placental abruption. A previa has painless bleeding and an abruption has pain with or without bleeding.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
.
Answer 1 is correct because the client likely has a placenta previa. Assessing the fetal heart tones for signs of fetal distress is the most important action. Answer 2 is incorrect because the client likely has a placenta previa, and a cervical examination is contraindicated. Answer 3 is incorrect because the client likely has a placenta previa. The uterus is firm with minimal relaxing with a placental abruption. Answer 4 is incorrect because, although the client likely has a placenta previa and obtaining maternal vital signs is important, assessing the fetal heart tones for signs of fetal distress is the most important action.