Which client is at greatest risk for early postpartum hemorrhage (PPH)?

Choice A reason: Dipstick value of 3+ for protein in her urine is a sign of significant proteinuria, which is one of the diagnostic criteria for preeclampsia, along with hypertension. Proteinuria indicates renal damage and impaired glomerular filtration, which can lead to complications, such as oliguria, eclampsia, or HELLP syndrome.

Choice B reason: Pitting pedal edema at the end of the day is a common and expected finding in pregnancy, as it results from the increased blood volume, venous pressure, and fluid retention. Edema is not a reliable indicator of preeclampsia, unless it is severe, generalized, or sudden.

Choice C reason: Weight gain of 0.5 kg during the past 2 weeks is a normal and expected finding in pregnancy, as it reflects the growth and development of the fetus, placenta, and maternal tissues. Weight gain is not a reliable indicator of preeclampsia, unless it is excessive, rapid, or associated with edema.

Choice D reason: Blood pressure (BP) increase to 138/86 mm Hg is a mild elevation that may indicate gestational hypertension, but not preeclampsia, unless it is accompanied by proteinuria or other signs of organ dysfunction. The diagnostic threshold for preeclampsia is a BP of 140/90 mm Hg or higher on two occasions at least four hours apart.

Choice A reason: Painless red vaginal bleeding is the most characteristic finding of placenta previa, which is a condition where the placenta covers the cervical opening and can cause bleeding in the third trimester. Painless red vaginal bleeding occurs because the placenta is detached from the lower uterine segment as the cervix dilates or effaces, and the blood vessels are torn. The bleeding can be mild or severe, and it can recur or persist until delivery.

Choice B reason: Intermittent abdominal pain following passage of bloody mucus is not a finding that supports placenta previa, but rather a finding that suggests normal labor or preterm labor. Intermittent abdominal pain is caused by uterine contractions, which can be regular or irregular, and can increase in frequency, duration, and intensity. Bloody mucus is the mucus plug that is expelled from the cervix as it dilates or effaces, and it can be tinged with blood or streaked with blood.

Choice C reason: Increasing abdominal pain with a nonrelaxed uterus is not a finding that supports placenta previa, but rather a finding that indicates abruptio placentae, which is a premature separation of the placenta from the uterine wall. Increasing abdominal pain is caused by the bleeding and the hematoma formation behind the placenta, which can compress the uterine muscle and the nerve endings. Nonrelaxed uterus is a sign of uterine hypertonicity, which can reduce the blood flow and the oxygen delivery to the fetus.

Choice D reason: Abdominal pain with scant red vaginal bleeding is not a finding that supports placenta previa, but rather a finding that suggests ectopic pregnancy, which is a condition where the fertilized ovum implants outside the uterine cavity, usually in the fallopian tube. Abdominal pain is caused by the rupture of the tube and the bleeding into the peritoneal cavity, which can irritate the diaphragm and the abdominal wall. Scant red vaginal bleeding is a sign of implantation bleeding, which can occur when the fertilized ovum attaches to the tube wall.