A client at 30 weeks' gestation is experiencing painless late vaginal bleeding. What should the nurse expect in the management of this client?
1. Assessing blood pressure every 2 hours
2. Evaluating the fetal heart rate with an internal monitor
3. Limiting vaginal examinations to only one per 24-hour period
4. Monitoring for blood loss, pain, and uterine contractibility
4
Explanation:
1. Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine basis or prn.
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.
3. Vaginal examinations are contraindicated because the examination can stimulate bleeding.
4. Blood loss, pain, and uterine contractibility need to be assessed for client comfort and safety.
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