A nurse in a prenatal clinic is examining the health record of a client who is 28 weeks pregnant.
The history includes one pregnancy terminated by elective abortion at 9 weeks, the birth of twins at 36 weeks, and a spontaneous abortion at 15 weeks.
According to the GTPAL system, how would you describe the client’s current status?

Choice A rationale

Inserting an indwelling urinary catheter is not the priority nursing action in this situation. While it may be necessary later in the care process, it is not the immediate concern when the client is experiencing a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. The priority is to stabilize the client and ensure the well-being of the fetus.

Choice B rationale

Witnessing the signature for informed consent for surgery is an important step before any surgical procedure. However, it is not the priority nursing action in this situation. The client’s condition could deteriorate rapidly due to the bleeding, and immediate medical interventions are necessary to stabilize the client and fetus.

Choice C rationale

Preparing the abdominal and perineal areas may be necessary if the client requires a surgical intervention. However, this is not the priority nursing action. The client is experiencing significant bleeding, and the priority is to stabilize the client’s condition.

Choice D rationale

Initiating IV access is the priority nursing action in this situation. The client is experiencing a large amount of painless, bright red vaginal bleeding, which could lead to hypovolemia and shock. IV access allows for the rapid administration of fluids and medications to stabilize the client’s condition.

Choice A rationale

While determining the viability of the fetus is an important aspect of prenatal care, it is not the primary purpose of an ultrasound in this scenario. The client’s report of feeling the baby moving suggests that the fetus is likely viable.

Choice B rationale

The primary purpose of the ultrasound in this scenario is to locate the placenta. Heavy, red vaginal bleeding at 38 weeks of gestation could indicate a complication such as placenta previa, where the placenta covers the cervix. An ultrasound can help confirm this diagnosis.

Choice C rationale

Measuring the biparietal diameter is a method used to estimate fetal weight and gestational age. However, in this scenario, the client is already known to be at 38 weeks of gestation, and the sudden onset of heavy, red vaginal bleeding is a more immediate concern.

Choice D rationale

Assessing fetal lung maturity is typically done when there is a risk of preterm delivery. In this scenario, the client is already at 38 weeks of gestation, which is considered full term. The immediate concern is the heavy, red vaginal bleeding.