A nurse is admitting a client who is at 36 weeks of gestation, has placenta previa, and has moderate vaginal bleeding.
Which of the following actions should the nurse take? (Select all that apply.)

Choice A rationale

A rigid, board like abdomen is a classic sign of concealed placental abruption, where blood accumulates between the placenta and the uterine wall. This causes the uterine muscle to become extremely irritable and hypertonic, resulting in a firm, tender, and non relaxing palpation. The trapped blood acts as an irritant to the myometrium, leading to this distinct physical finding which can signal significant maternal hemorrhage and potential fetal distress due to compromised uteroplacental perfusion.

Choice B rationale

Vaginal bleeding occurs in external placental abruption when the blood dissects the membranes away from the uterine wall and escapes through the cervix. The blood is typically dark red due to its origin from the retroplacental space. While some abruptions are concealed and show no bleeding, many present with some degree of visible hemorrhage. This loss of blood can lead to maternal hypovolemia and decreased oxygen delivery to the fetus, necessitating immediate monitoring and possible delivery.

Choice C rationale

Back pain is a common symptom of placental abruption, especially when the placenta is located on the posterior wall of the uterus. The pain is often described as a dull, constant ache or sharp tenderness. This occurs because the expanding hematoma creates pressure against the sensitive uterine tissues and pelvic nerves. This discomfort is different from the intermittent pain of normal contractions and should alert the nurse to the possibility of premature separation of the placenta.

Choice D rationale

Frequent uterine contractions or uterine tachysystole occur because the blood infiltrating the myometrium causes high resting tone and muscle irritability. The uterus may fail to relax completely between contractions, which is seen on a fetal monitor as an elevated baseline. This hyperactivity can further compromise fetal oxygenation by compressing the blood vessels in the decidua. Recognizing this pattern is vital for the nurse to identify an abruption before it progresses to a complete detachment.

Choice E rationale

Headache is not a primary manifestation of placental abruption and is more frequently associated with hypertensive disorders of pregnancy such as preeclampsia. In preeclampsia, vasospasm and cerebral edema cause the headache. While a client with abruption could have a headache due to stress or unrelated causes, it does not scientifically stem from the premature separation of the placenta. The priority assessment in abruption focuses on abdominal pain, uterine tone, and the characteristics of any vaginal bleeding.

Choice A rationale

Gestational hypertension is characterized by a blood pressure of 140/90 mm Hg or greater that occurs after the 20th week of pregnancy in a previously normotensive woman. However, it lacks the presence of proteinuria or systemic signs of end-organ dysfunction. In this case, the blood pressure readings are significantly higher and are accompanied by neurological symptoms, which points toward a more advanced and dangerous hypertensive disorder of pregnancy rather than simple gestational hypertension.

Choice B rationale

Chronic hypertension refers to high blood pressure that was present before the pregnancy began or was diagnosed before the 20th week of gestation. This condition persists beyond 12 weeks postpartum. While chronic hypertension increases the risk for developing superimposed preeclampsia, the acute presentation of severe blood pressure elevations and neurological symptoms like blurred vision and a frontal headache at 30 weeks gestation specifically indicates an acute hypertensive crisis related to the current pregnancy.

Choice C rationale

Preeclampsia without severe features is defined by a blood pressure ≥ 140/90 mm Hg but < 160/110 mm Hg, along with proteinuria. The client in this scenario has blood pressure readings exceeding 160/110 mm Hg, which automatically moves the diagnosis into the severe category. Furthermore, the presence of blurred vision and a persistent headache are considered "severe features" or "danger signs" that indicate central nervous system involvement, necessitating more intensive monitoring and medical intervention.

Choice D rationale

Preeclampsia with severe features is diagnosed when a pregnant woman after 20 weeks gestation has a systolic blood pressure ≥ 160 mm Hg or diastolic ≥ 110 mm Hg on two occasions. The presence of end-organ symptoms, such as the blurred vision and persistent frontal headache reported here, confirms this diagnosis. These symptoms suggest cerebral edema or vasospasm, which are critical markers of disease severity and indicate an increased risk for progression to eclamptic seizures.