Upon arrival at the emergency room, place the woman flat in bed.
Assess the vital signs to establish baseline data and determine if the patient is under shock.
Maintain accurate intake and output to establish the patient’s renal function.
Monitor maternalvital signs to determine the presence of hypotensionand tachycardiacaused byrupture or hemorrhage. Vital signs, especially the blood pressure and pulse rate, should be stable and within the normal range.
Patient must exhibit moist mucous membranes, good skin turgor, and adequate capillary refill.
Monitor intake and output. The patient must maintain adequate fluid volume at a functional level as evidenced by normal urine output at 30-60mL/hr and a normal specific gravity between the ranges of 1.010 to 1.021.
Monitor for presence andamount of vaginal bleeding to further assess thepresentsituationindicatinghemorrhage.
Monitor for increase and painand abdominaldistention andrigidity since increased painand abdominaldistentionindicatesrupture andpossibleintra-abdominalhemorrhage.
Monitor completeblood count(CBC) to determinethe amount of blood loss.
Provide comfort measures likeback rubs, deepbreathing.Instruct inrelaxation or visualizationexercises.Providediversional activities since these promote relaxation andmay enhancepatient’s copingabilities byrefocusingattention.
Diversionalactivities aids inrefocusingattention andenhancingcoping withlimitations.
Administer analgesics as indicated to maintainacceptablelevel of pain.
