Placenta Previa vs Abruption on the NCLEX
Painless vs painful bleeding, why previa forbids vaginal exams, and the nursing priorities for each.
Two causes of late-pregnancy bleeding, one discriminator: pain. NCLEX tests the contrast and the exam you must not do.
Placenta previa
Placenta implants over or near the cervical os. Painless, bright red vaginal bleeding, often in the third trimester. Uterus soft and nontender. Fetus frequently stable. Diagnosed by ultrasound placental location. Risk factors: prior cesarean, prior previa, multiparity, advanced maternal age, smoking.
Abruption
Placenta detaches from the uterine wall before delivery. Painful, dark red bleeding, or concealed bleeding with no visible blood. Uterus rigid, board-like, tender, often with high-frequency low-amplitude contractions. Fetal distress is common. Risk factors: hypertension (including pre-eclampsia), abdominal trauma, cocaine use, smoking, prior abruption. DIC is the feared maternal complication.
The rule NCLEX always tests
No vaginal or rectal exams with undiagnosed late-pregnancy bleeding. A finger through a previa can tear the placenta and cause catastrophic hemorrhage. Ultrasound locates the placenta first. This includes withholding any provider-ordered exam until previa is ruled out; question the order.
Nursing priorities for both
Large-bore IV access, type and crossmatch, continuous fetal monitoring, maternal vitals for hypovolemia (tachycardia precedes hypotension), strict pad counts, side-lying position. Previa with heavy bleeding or complete previa → cesarean delivery. Abruption with fetal distress or maternal instability → emergency cesarean. For abruption, also watch coagulation labs (fibrinogen, platelets) for DIC.
Frequently asked
Bright red painless bleeding at 32 weeks. Most likely?
Previa until ultrasound says otherwise. No vaginal exam, start monitoring, notify the provider.
Can abruption present without visible bleeding?
Yes. A concealed abruption traps blood behind the placenta. Rigid tender uterus, worsening pain, and fetal distress with a stable-looking pad is the classic concealed picture.
Why does the abruption patient need fibrinogen levels?
Abruption releases tissue factor and consumes clotting factors, which can trigger DIC. Falling fibrinogen and platelets with oozing from IV sites is the pattern.
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