What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?
A.
Assessing fetal heart rate (FHR) and maternal vital signs
B.
Performing a venipuncture for hemoglobin and hematocrit levels
C.
Monitoring uterine contractions
D.
Placing clean disposable pads to collect any drainage
The Correct Answer and Explanation is:
The highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is A. Assessing fetal heart rate (FHR) and maternal vital signs.
Explanation:
When a pregnant woman presents with a bleeding episode, particularly in the late stages of pregnancy, immediate assessment of both fetal and maternal well-being is critical. The priority lies in ensuring the safety of both the mother and the fetus.
Fetal Heart Rate (FHR) Assessment: Monitoring the FHR is essential because changes in the fetal heart rate can indicate fetal distress, which may be caused by compromised placental blood flow due to bleeding. A normal FHR range (typically between 110 and 160 beats per minute) suggests that the fetus is likely tolerating the situation well, whereas an abnormal FHR (such as bradycardia or tachycardia) may signal the need for urgent intervention.
Maternal Vital Signs: Concurrently, assessing maternal vital signs—such as blood pressure, heart rate, and respiratory rate—is crucial. Changes in these parameters can indicate significant blood loss and hypovolemia, which can lead to shock. For instance, a drop in blood pressure or an increase in heart rate can reflect a compensatory mechanism in response to hypovolemia, necessitating immediate medical attention.
Other Options: While performing a venipuncture for hemoglobin and hematocrit levels (Option B) and monitoring uterine contractions (Option C) are important nursing interventions, they can follow after the initial assessment. Placing clean disposable pads (Option D) can help collect drainage but does not directly assess the immediate health status of the mother and fetus.
In summary, the primary goal in such a situation is to ensure the safety and stability of both the mother and the fetus, making the assessment of fetal heart rate and maternal vital signs the top priority in the nursing intervention plan.