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Difficulty: MediumAbuse and Neglect

A nurse in a prenatal clinic is assessing a 26-year-old client at 28 weeks of gestation. The nurse observes yellow and purple bruising on the client's upper arms and neck. The client's partner is present in the examination room, sits between the client and the door, and repeatedly answers questions that the nurse directs at the client. Which of the following is the priority nursing action?

  1. Tell the client that a routine urine sample is needed and escort the client to the restroom alone.Answer
  2. B
    Ask the partner directly how the client sustained the visible bruising.
  3. C
    Notify local law enforcement immediately to report suspected intimate partner violence.
  4. D
    Document the objective characteristics of the bruises and complete the standard prenatal assessment.

Answer

Tell the client that a routine urine sample is needed and escort the client to the restroom alone.
When intimate partner violence (IPV) is suspected, the nurse must assess the client in a private, safe environment. Using a routine clinical procedure, such as requesting a urine sample, provides a plausible and non-threatening reason to separate the client from the partner without triggering suspicion or immediate escalation.

Step-by-Step Solution

1
Identify clinical and behavioral signs of potential intimate partner violence (IPV).
The nurse notes physical injuries (bruising in various stages) and controlling behavior by the partner (answering questions, blocking the exit).
Recognizing red flags for IPV is the first step in formulating a safe plan of care.
2
Determine the highest priority need for the client based on the assessment.
The priority is establishing immediate physical and emotional safety to facilitate open communication.
Clients experiencing IPV will rarely disclose abuse if the perpetrator is present in the room.
3
Implement a safe strategy to separate the client from the partner.
The nurse uses a standard prenatal procedure (collecting a urine specimen) to escort the client out of the room alone.
Using a routine clinical rationale prevents arousing the partner's suspicion, thereby avoiding escalation and protecting the client from retaliation.

Key Concept

In cases of suspected Intimate Partner Violence (IPV), the priority is to separate the client from the suspected abuser safely and non-confrontationally to allow for private assessment.
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Topics

Abuse and Neglect

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