The provider orders an infusion of oxytocin to prevent postpartum hemorrhage at 20 mU/min.

The availability of the oxytocin infusion is 20 units/1000 mL of normal saline.

How many mL/hr will the oxytocin infuse. (Record numerical answers only. Round the answer to the nearest whole number.)

Choice A rationale

Fundal height measurement assesses fetal growth, which is important but less critical than fetal well-being in a bleeding emergency. Placenta previa involves placental implantation near or over the cervical os, causing painless bleeding. Fetal distress from hypovolemia or prematurity is the most immediate life threat. The normal fundal height range is approximately equal to the weeks of gestation ± 2 cm after 20 weeks.

Choice B rationale

A digital vaginal examination is contraindicated in a client with painless, bright red bleeding suspicious of placenta previa. This action could accidentally rupture the placenta or vessels, leading to catastrophic hemorrhage and fetal distress by potentially causing placental separation or tearing of the vasa previa if present.

Choice C rationale

Assessment of maternal temperature is part of a routine vital sign assessment, mainly to detect infection (chorioamnionitis), which can cause preterm labor or rupture of membranes, but is not the priority over assessing the immediate maternal and fetal response to the hemorrhage. Normal maternal temperature is about 36.1°C to 37.2°C (97.0°F to 99.0°F).

Choice D rationale

Continuous monitoring of the fetal heart rate (FHR) and contraction patterns is the most crucial assessment to determine fetal status and well-being. Bleeding from placenta previa can quickly compromise uteroplacental perfusion, leading to fetal hypoxia, distress (e.g., non-reassuring FHR patterns), or premature labor, necessitating immediate intervention. Normal FHR is 110-160 beats per minute.

Choice A rationale

Placing a rolled towel under the client's knees causes increased pressure on the popliteal space, potentially compressing the popliteal vein, which increases the risk of deep vein thrombosis (DVT) in the client. This is particularly concerning during labor due to physiologic hypercoagulability and potential for immobility. The priority action must focus on fetal and maternal well-being following rupture of membranes (ROM). This action is non-essential and potentially harmful.

Choice B rationale

While notifying the healthcare provider is crucial, it is not the immediate priority when there is a risk of a severe complication like umbilical cord prolapse following the spontaneous rupture of membranes (ROM). The nurse's immediate action must be to rule out or intervene for fetal distress or cord prolapse. The provider can be notified after the initial fetal status assessment is complete, especially the fetal heart rate (FHR).

Choice C rationale

Administering oxygen via a non-rebreather mask (NRB) is indicated for maternal or fetal hypoxemia or distress, or as part of resuscitation measures. In an initially stable client without signs of severe respiratory distress or non-reassuring fetal heart rate (FHR) patterns, oxygen administration is not the priority. The initial action must be a rapid assessment of fetal status, specifically ruling out cord prolapse after rupture of membranes (ROM).

Choice D rationale

Rupture of membranes (ROM) prior to the fetal head being engaged or firmly applied to the cervix creates a significant risk for umbilical cord prolapse, which is a fetal emergency causing acute fetal hypoxemia due to cord compression. The immediate priority is to assess the fetal heart rate (FHR) and perform a sterile vaginal exam (SVE) to palpate for the prolapsed cord and assess the presenting part. FHR assessment detects distress; SVE detects the prolapse.