For which client condition would the triage nurse give a red tag based on priority?

Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus. It is the most common cause of painless bleeding in the third trimester of pregnancy. It occurs in four degrees: low-lying placenta, which is implantation in the lower rather than in the upper portion of the uterus; marginal implantation, in which the placenta edge approaches that of the cervical os; partial placenta previa, which is implantation that occludes a portion of the cervical os; and total placenta previa, in which the implantation totally obstructs the cervical os.

Inhaltsverzeichnis Show

Risk for Deficient Fluid Volume
Which client would be triaged first based on condition?
Which client should the nurse consider to need the highest priority care?
Which action would the nurse perform as the highest priority for a client with trauma?
For which client conditions would the emergency department nurse stabilize the cervical spine as the priority nursing intervention quizlet?

Increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestations, and perhaps a male fetus are all associated with placenta previa.

Painless vaginal bleeding, usually bright red, is the main characteristic of placenta previa. The bleeding in placenta previa doesn’t usually begin, however, until the lower uterine segment starts to differentiate from the upper segment late in pregnancy (week 30) and the cervix begins to dilate. At this point, because the placenta is unable to stretch to accommodate the different shapes of the lower uterine segment or the cervix, a small portion loosens, and damaged blood vessels begin to bleed.

Nursing care management and treatment of placenta previa is designed to assess, control, and restore blood loss and to deliver a viable infant. Immediate therapy includes starting an IV line using a large bore catheter.

Risk for Deficient Fluid Volume

The bleeding of placenta previa, like that of ectopic pregnancy, creates an emergency situation as the open vessels of the uterine decidua place the client at risk for hemorrhage. Postpartum hemorrhage may occur because the lower uterine segment, where the placenta was attached, has fewer muscle fibers than the upper uterus. The resulting weak contraction of the lower uterus does not compress the open blood vessels at the placental site as effectively as would the upper segment of the uterus.

Nursing Diagnosis

Risk for Deficient Fluid Volume

Risk Factors

Excessive vaginal bleeding
Damaged uterine blood vessels

Possibly evidenced by

(Not applicable; the presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes

The client will maintain fluid volume at a functional level, possibly evidenced by adequate urinary output and stable vital signs.
The client will display homeostasis as evidenced by the absence of bleeding.

Nursing Assessment and Rationales

1. Assess color, odor, consistency, and amount of vaginal bleeding.
Inspect the perineum for bleeding and estimate the present rate of blood loss.The bleeding with placenta previa is usually abrupt, painless, bright red, and sudden. The bleeding may be provoked by intercourse, vaginal examinations, or labor, and at times there may be no identifiable cause (Anderson-Bagga & Sze, 2019).

2. Monitor the client’s vital signs.
Obtain baseline vital signs to determine whether symptoms of hypovolemic shock are present. Continue to assess blood pressure every 5 to 15 minutes or continuously with an electronic cuff. Signs of hypovolemic shock include hypotension, tachycardia, and tachypnea.

3. Assess hourly intake and output.
Monitor urine output frequently, as often as every hour, as an indicator that the client’s blood volume is remaining adequate to perfuse her kidneys.

4. Assess abdomen for tenderness or rigidity- if present, measure abdomen at the umbilicus (specify time interval).
A thorough abdominal examination to identify uterine tenderness can be useful in differentiating other causative factors for vaginal bleeding, including uterine rupture and placental abruption. Measure the abdominal girth to determine if the bleeding is progressing (Bakker & Smith, 2018).

5. Monitor the fetal heart rate and uterine contractions continuously.
Attach external monitoring equipment to record fetal heart sounds and uterine contractions; however, avoid the use of an internal monitor for either fetal or uterine assessment to prevent hemorrhage. Fetal hypoxia may occur if a large disruption of the placental surface reduces the transfer of oxygen and nutrients.

Nursing Interventions and Rationales

1. Weigh perineal pads to estimate blood loss.
Weighing perineal pads before and after use and calculating the difference by subtraction is a good method to determine vaginal blood loss.

2. Avoid vaginal examinations.
Because of the risk of provoking life-threatening hemorrhage, a digital examination of the vagina is absolutely contraindicated until placenta previa is excluded. Instruments should not be placed near the cervix because uncontrolled bleeding can result (Bakker & Smith, 2018). If placenta previa is suspected and ultrasound is unavailable, the provider may perform a vaginal examination with preparations for both vaginal and cesarean births (a double set-up) in place.

3. Position the client supine with hips elevated if ordered or in a left side-lying position.
To ensure an adequate blood supply to the client and fetus, place the client immediately on bed rest in a left side-lying position. The left side-lying position decreases pressure on the placenta and cervical os and improves placental perfusion.

4. Review ultrasound and laboratory results.
Routine sonography in the first and second trimesters of pregnancy provides early identification of placenta previa. A follow-up sonogram is recommended at 28 to 32 weeks of gestation to look for persistent placenta previa (Bakker & Smith, 2018). If there is a concern for placenta previa, then a transvaginal sonogram should be performed to confirm the location of the placenta. Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time, fibrinogen, platelet count, type and cross-match, and antibody screen is assessed to establish baselines, detect a possible clotting disorder, and ready blood for replacement if necessary.

5. Perform an Apt or Kleihauer-Betke test.
If there is concern about fetal-maternal transfusion, a Kleihauer-Betke test can be performed. These are test strip procedures that can be used to detect whether the blood is fetal or maternal in origin.

6. Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-12 L/min.
Have oxygen equipment available in case the fetal heart sounds indicate fetal distress, such as bradycardia or tachycardia, late deceleration, or variable decelerations during the exam.Oxygen supplementation increases available oxygen to saturate decreased hemoglobin.

7. Initiate IV fluids as ordered (specify fluid type and rate).
Administer intravenous fluid as prescribed, preferably with a large-gauge catheter to allow for blood replacement through the same line. Attach Ringer’s lactate or normal saline at a rapid rate if a shock is present. Reduce the infusion rate to 3 ml/min when the pulse slows down to less than 100 beats/min and systolic BP increases to 100 mm Hg or higher (World Health Organization, 2015).

8. Administer tocolytic agents as prescribed.
Tocolysis may be considered in cases of minimal bleeding and extreme prematurity in order to administer antenatal corticosteroids. One study appeared to suggest that the use of tocolytics increases the pregnancy duration and the baby’s birth weight without causing adverse effects on the mother and the fetus (Bakker & Smith, 2018).

9. Administer blood and blood products as indicated.
In instances where significant bleeding ensues, rapid replacement of blood products is a priority. Activation of the Massive Transfusion Protocol is warranted, allowing for stabilization of the client’s hemodynamic status by way of a rapid supply of blood products (Bakker & Smith, 2018).

10. Prepare for a vaginal or cesarean birth.
Vaginal birth is always safest for the infant. If the previa is under 30% by abdominal or transvaginal ultrasound, it may be possible for the fetus to be born past it. If over 30% and the fetus is mature, the safest birth method for both mother and baby is often cesarean birth.

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Which client would be triaged first based on condition?

Triage categories Highest priority is given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized. Second-highest priority is given to clients who have major injuries that are not yet life-threatening and can usually wait 30 minutes to 2 hours for treatment.

Which client should the nurse consider to need the highest priority care?

On nursing exams, there will often be questions regarding the prioritization of patients. Often these questions will ask, “Which patient is a priority?” Patients with problems regarding airway, breathing and circulation should always be the priority, and it should always be in that order.

Which action would the nurse perform as the highest priority for a client with trauma?

The first priority in any emergency is always an adequate airway. The nurse is involved in clearing the mouth, inserting an oral airway, assisting with intubation, oxygen therapy and assessing continually the patient's respiratory system.

For which client conditions would the emergency department nurse stabilize the cervical spine as the priority nursing intervention quizlet?

Immediate care for a client with a head injury and facial chemical burns is stabilization of the cervical spine because the client may suffer severe respiratory distress.