A nurse is caring for a female client who is at 12 weeks of gestation in the prenatal clinic.

Exhibits

A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

Choice A rationale

A fetal heart rate (FHR) of 150/min with moderate variability is within the normal range (110-160/min) and suggests adequate fetal oxygenation, which is less indicative of a significant Grade 2 abruption. A Grade 2 (moderate) abruption typically involves 20%-50% placental separation, often resulting in fetal distress like persistent late decelerations or tachycardia as a compensatory response to hypoxemia.

Choice B rationale

Placenta previa, not abruption, classically presents with painless, bright red vaginal bleeding due to the placenta covering the cervical os. Placental abruption, caused by premature separation of the placenta from the uterine wall, typically causes bleeding accompanied by significant, severe, and unrelenting abdominal pain due to concealed hemorrhage and uterine irritability.

Choice C rationale

A soft abdomen suggests a relaxed uterus, which is normal. In Grade 2 placental abruption, blood often becomes trapped between the placenta and uterine wall, causing uterine tetany or hypertonicity (increased muscle tone) and rigidity, which presents as a firm or board-like abdomen that is tender to palpation.

Choice D rationale

A heart rate of 120/min (tachycardia) in the client is an expected finding in a moderate (Grade 2) placental abruption. The client is experiencing hypovolemia due to hemorrhage (internal and/or external bleeding), which triggers a compensatory sympathetic nervous system response, increasing the heart rate to maintain cardiac output and tissue perfusion.

Choice A rationale

For a client with moderate abruptio placenta, which involves premature separation of the placenta from the uterine wall, the primary concern is fetal well-being due to impaired oxygen and nutrient exchange, and maternal hemorrhage. Therefore, continuous monitoring of fetal heart rate (FHR) tracings is a priority to assess for signs of fetal compromise (e.g., late decelerations, bradycardia, nonreassuring patterns) and determine the urgency for delivery.

Choice B rationale

Ferning is a microscopic test where a sample of vaginal fluid is allowed to dry on a slide; the characteristic fern pattern indicates the presence of amniotic fluid. This test is used to confirm rupture of membranes. This is not the immediate priority intervention for abruptio placenta, which is focused on managing hemorrhage and fetal distress, and a vaginal examination may be contraindicated if bleeding is severe.

Choice C rationale

Assessing for cervical dilation requires a vaginal examination. While important for determining labor progression, a vaginal examination is often contraindicated in the setting of unexplained vaginal bleeding until a placenta previa is ruled out by ultrasound, as a digital exam could potentially cause a severe hemorrhage if the placenta is covering the cervix. The FHR is a higher priority.

Choice D rationale

Administering oxytocin is a uterotonic agent used to induce or augment labor. In moderate to severe abruptio placenta, if the client is not in active labor or the bleeding is significant, emergency cesarean delivery might be required. Furthermore, the goal is often to deliver the fetus as quickly and safely as possible; oxytocin is not the initial management and could increase uterine tone, potentially worsening the abruption if not used carefully under close monitoring.