A nurse is formulating a care plan for a patient who is 10 weeks pregnant and reports abdominal pain and moderate vaginal bleeding.
The preliminary diagnosis is an inevitable abortion.
Which nursing interventions should be included in the care plan?

Choice A rationale

While it’s important for the nurse to provide reassurance and support during the exam, this statement alone doesn’t address the client’s specific concerns or provide any useful information.

Choice B rationale

Telling the client to relax doesn’t address her concerns or provide any useful information. It’s normal to feel nervous before a pelvic exam, especially if it’s the first one.

Choice C rationale

Asking the client what part of the exam makes her most nervous allows the nurse to provide specific information and reassurance, which can help alleviate the client’s anxiety.

Choice D rationale

While a pelvic exam is often part of the process when starting oral contraceptives, it’s not always required. The need for a pelvic exam can depend on the client’s age, sexual history, and other factors.

The correct answer is Choice C.

Choice A rationale: Inserting an IV catheter is important for potential fluid and medication administration, but it is not the immediate priority action.

Choice B rationale: Administering glucocorticoids is important for fetal lung maturity in case of preterm birth, but it is not the immediate priority upon admission.

Choice C rationale: Applying an external fetal monitor is the priority action. It allows for continuous monitoring of the fetal heart rate and uterine activity to assess the well-being of the fetus and detect any signs of distress.

Choice D rationale: Monitoring vaginal bleeding is important for managing placenta previa, but it is not the immediate priority. Continuous fetal monitoring takes precedence to ensure fetal safety.