The nurse is supervising care in the emergency department. Which situation most requires an intervention?
1. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer's solution running at 125 mL/hour
2. Spotting of pinkish-brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour
3. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20
4. Dark red bleeding at 30 weeks' gestation with normal vital signs; patient reports an absence of fetal movement
3
Rationale 1: Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss can be heavy and rapid, so having an IV stabilizes the client's vascular volume.
Rationale 2: Bleeding in the first trimester can be indicative of spontaneous abortion beginning, or of an ectopic pregnancy. An ultrasound will diagnose which situation is occurring, and will determine care.
Rationale 3: Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss can be heavy and rapid. This patient has a low blood pressure with an increased pulse rate, which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby.
Rationale 4: Watery, dark red bleeding in the third trimester can indicate placental abruption with ruptured membranes. Normal vital signs indicate a normal vascular volume. A lack of fetal movement could indicate fetal hypoxia or fetal demise. The fetus is at greatest risk in this situation; the mother is stable.
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