The patient at 30 weeks' gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes:
1. Limiting vaginal exams to only one per 24-hour period.
2. Evaluating the fetal heart rate with an internal monitor.
3. Monitoring for blood loss, pain, and uterine contractibility.
4. Assessing blood pressure every 2 hours.
Correct Answer: 3
Rationale 1: Vaginal exams are contraindicated because the exam can stimulate bleeding.
Rationale 2: Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal monitor.
Rationale 3: Blood loss, pain, and uterine contractibility need to be assessed for patient comfort and safety.
Rationale 4: Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine basis or p.r.n.
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