A nurse is caring for a client at a 10-week prenatal visit. The provider diagnoses the client with a missed spontaneous abortion confirmed by ultrasound and the nurse is discussing the plan of care with the client.
Which of the following statements should the nurse make?

Choice A rationale

Bladder distention upon palpation indicates urinary retention, not effective voiding. When the bladder remains distended, it signifies incomplete emptying, which can lead to urinary stasis and increased risk of urinary tract infections. Effective voiding requires coordinated detrusor muscle contraction and urethral sphincter relaxation, which is absent with distention.

Choice B rationale

A uterine fundus 2 cm above the umbilicus, especially in the postpartum period, suggests uterine atony and possible bladder distention. A full bladder can displace the uterus upward and to the side, preventing effective uterine contraction and involution, which is crucial for preventing postpartum hemorrhage. Normal fundal height should decrease daily.

Choice C rationale

Not feeling the urge to urinate could indicate nerve damage, overdistention with sensory nerve suppression, or a very low urine output. Normal bladder sensation is crucial for effective voiding. The absence of the urge may lead to prolonged bladder distention, increasing the risk of infection and bladder dysfunction, which hinders efficient emptying.

Choice D rationale

Urinating 30 mL/hr, while seemingly low, is a continuous output and suggests the client is able to empty their bladder, albeit slowly. Postpartum diuresis typically begins within 12 hours, with urine output of 100 to 250 mL/hr common. However, any consistent output, rather than retention, indicates some voiding effectiveness.

Rationale for correct condition
Placenta previa occurs when the placenta partially or completely covers the cervical opening, causing painless bright red vaginal bleeding during the second or third trimester. The client’s presentation of painless vaginal bleeding without contractions or abdominal tenderness supports this diagnosis. Fundal height measuring 27 cm at 28 weeks aligns with normal gestation, and the absence of uterine irritability or pain differentiates it from abruptio placentae. Fetal heart rate of 170/min with minimal variability reflects fetal stress but no immediate decelerations. These features are consistent with placenta previa rather than other causes of bleeding.

Rationale for correct actions
Strict bed rest reduces mechanical disruption of the placenta previa site, minimizing further bleeding risk and improving maternal-fetal oxygenation. Large-bore IV access is essential to rapidly administer fluids or blood products if hemorrhage occurs, maintaining maternal hemodynamic stability. Both actions are critical for managing acute vaginal bleeding while ensuring safety until delivery or further intervention.

Rationale for correct parameters
Monitoring fetal well-being via continuous electronic fetal monitoring detects signs of hypoxia or distress, guiding timely interventions. Tracking vaginal bleeding quantifies blood loss and progression, essential to assess severity and need for transfusion. Both parameters directly evaluate maternal and fetal status during placenta previa management.

Rationale for incorrect conditions
Abruptio placentae involves premature placental separation causing painful bleeding and uterine tenderness, absent here. Chorioamnionitis presents with maternal fever, uterine tenderness, and fetal tachycardia due to infection, none reported. Vasa previa entails fetal vessel rupture causing rapid fetal distress and bleeding; no signs of fetal demise or sudden distress are evident.

Rationale for incorrect actions
Administering pitocin is contraindicated as it may cause contractions worsening bleeding in placenta previa. Methotrexate treats ectopic pregnancy or trophoblastic disease, unrelated here. Vaginal examination risks provoking hemorrhage and is avoided in placenta previa.

Rationale for incorrect parameters
White blood cell count monitors infection, not relevant in this case without fever or leukocytosis. Cervical dilation monitoring is contraindicated due to risk of hemorrhage in placenta previa. Beta-human chorionic gonadotropin levels evaluate pregnancy viability or trophoblastic disease, irrelevant here.

Take home points

• Placenta previa presents as painless bright red bleeding in the third trimester.
• Avoid vaginal examinations to prevent hemorrhage in placenta previa.
• Strict bed rest and IV access are critical management steps.
• Differentiate placenta previa from abruptio placentae by pain and uterine tenderness.