The nurse has received end of shift report in the high-risk maternity unit. Which client should the nurse see first?
1. 35 weeks' gestation with grade 1 abruptio placentae in labor who has a strong urge to push
2. 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations
3. 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement
4. 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously
3
Explanation:
1. Grade 1 abruptio placentae creates slight vaginal bleeding. The urge to push indicates that delivery is near. This client is not the highest priority.
2. Late decelerations are an abnormal finding, but put only the fetus at risk. This client is not the highest priority.
3. Bleeding with a placenta previa is a complication that can be life threatening to both the mother and baby. This client is the highest priority.
4. Although pregnancy-induced hypertension increases the risk for developing abruptio placentae, there is no indication that this client is experiencing this complication. This client is not the highest priority.
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