A pregnant primigravida client has bruises on the upper arms after an incident with her partner. What is the priority nursing action?

A pregnant primigravida client has bruises on the upper arms after an incident with her partner. What is the priority nursing action?

• A. Developing a safety plan with the client
• B. Scheduling a divorce lawyer appointment
• C. Providing sedative medication
• D. Encouraging the partner to stay away only during pregnancy

Answer: (A)

Prioritizing safety and risk assessment is essential when a pregnant patient shows signs of partner violence. The nurse’s first goal is to help the patient develop a plan to stay safe, so she can leave if danger worsens and seek help promptly, protecting both her and the fetus. This involves practical steps like identifying a safe place to go, having a trusted person to contact in an emergency, keeping essential items ready (identification, medications, money, keys), ensuring access to a phone, knowing how to contact emergency services, and connecting with shelters or domestic violence resources. It also includes private, nonjudgmental dialogue to assess danger cues and to empower the patient with information and options, while documenting injuries and ensuring confidentiality. Other actions don’t address immediate safety. Scheduling a divorce lawyer appointment targets long-term legal action rather than the present risk. Providing sedative medication is inappropriate and could impair judgment or safety. Encouraging the partner to stay away only during pregnancy fails to address the ongoing risk and doesn’t equip the patient with tools to stay safe if the abuse continues or escalates. The safety plan approach is the responsible, patient-centered first step in this scenario.

Prioritizing safety and risk assessment is essential when a pregnant patient shows signs of partner violence. The nurse’s first goal is to help the patient develop a plan to stay safe, so she can leave if danger worsens and seek help promptly, protecting both her and the fetus. This involves practical steps like identifying a safe place to go, having a trusted person to contact in an emergency, keeping essential items ready (identification, medications, money, keys), ensuring access to a phone, knowing how to contact emergency services, and connecting with shelters or domestic violence resources. It also includes private, nonjudgmental dialogue to assess danger cues and to empower the patient with information and options, while documenting injuries and ensuring confidentiality.

Other actions don’t address immediate safety. Scheduling a divorce lawyer appointment targets long-term legal action rather than the present risk. Providing sedative medication is inappropriate and could impair judgment or safety. Encouraging the partner to stay away only during pregnancy fails to address the ongoing risk and doesn’t equip the patient with tools to stay safe if the abuse continues or escalates. The safety plan approach is the responsible, patient-centered first step in this scenario.