A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take?
Explanation & Rationale
A. Rupture the amniotic sac: Artificial rupture of membranes is contraindicated in complete placenta previa because it can trigger severe maternal hemorrhage due to placental location over the cervical os. B. Medicate the client for pain: While pain management may be necessary, the immediate priority is maternal and fetal safety. Pain control does not address the life-threatening risk of bleeding with placenta previa. C. Prepare the client for a cesarean section: Complete placenta previa requires delivery by cesarean section to prevent catastrophic hemorrhage. Preparing for surgery is the priority intervention for both maternal and fetal safety. D. Perform a vaginal exam: Vaginal examination is contraindicated in complete placenta previa because it can disrupt the placenta and cause severe bleeding. It should not be performed.