A 28-year-old woman at 32 weeks gestation presents to the emergency department with sudden onset of severe abdominal pain and bright red vaginal bleeding. Her vital signs are: BP 90/50 mmHg, HR 120 bpm, RR 24/min. The fetal heart rate shows late decelerations. What is the priority nursing intervention?
1Perform a sterile vaginal examination to assess cervical dilation
2Administer tocolytic medications to stop uterine contractions
3Establish large-bore IV access and prepare for emergency cesarean delivery✓ 정답
4Position the patient in Trendelenburg position to improve blood flow
해설
Priority is establishing large-bore IV access for fluid resuscitation and preparing for emergency cesarean delivery due to maternal hemodynamic instability (BP 90/50, HR 120) and fetal distress (late decelerations). Other options are contraindicated or lower priority in this acute setting.
Clinical Judgment
This question evaluates priority setting in a life-threatening obstetric emergency called Placental Abruption. The key is to simultaneously recognize factors threatening the lives of both the mother and the fetus and select the most urgent action. The patient is hemodynamically unstable with hypotension (90/50) and tachycardia (120), and the fetus is experiencing hypoxia indicated by Late Decelerations. In this situation, the greatest dangers are progressive maternal hemorrhage and fetal hypoxic injury. Therefore, the priority is to simultaneously begin preparing for resuscitation to maintain the mother's blood circulation and preparing for immediate delivery to save the fetus. Option 3 is the only comprehensive intervention that fulfills both of these goals.
Memory Tip:
Acronym to remember in a placental abruption emergency: ABC & D.
Access (secure a large-bore IV line), Blood (prepare blood products), C-section (prepare for cesarean section), Don't delay. A sterile vaginal examination or administering uterine relaxants can worsen the situation.
KR vs US:
In Korea, even if the fetal condition is critical, an approach focusing on stabilizing the mother before considering delivery may be more common. However, in the US NGN/CJMM, when risks to the mother and fetus exist simultaneously, the core principle is to immediately initiate comprehensive and rapid actions to address the most urgent life threats. The act of "Prepare" itself is already considered an essential nursing intervention.
Clinical Practice GuideWhen evaluating a patient with suspected placental abruption:1. Do not perform a sterile vaginal exam (No Vaginal Exam!): This can further detach the already separated placenta and worsen bleeding.2. Position the patient in the left lateral position: This reduces compression of the inferior vena cava and improves placental perfusion. The Trendelenburg position is not recommended.3. Continuous monitoring: Continuously assess maternal vital signs, amount of bleeding, uterine tone, and fetal heart rate.4. Team communication: Immediately notify the surgery, anesthesia, and neonatal intensive care unit (NICU) teams.
Caution:These are items that frequently appear as traps in SATA (Select All That Apply) questions: "performing a sterile vaginal exam," "administering uterine relaxants," and "placing in Trendelenburg position." These three interventions are generally contraindicated or inappropriate in the setting of placental abruption.
Placental Abruption (태반조기박리) — A condition where the placenta partially or completely separates from the uterine wall before delivery. It is a life-threatening emergency for both mother and fetus, characterized by painful vaginal bleeding.
Late Decelerations (후기 감속) — A decrease in fetal heart rate that begins after the peak of a uterine contraction and persists even after the contraction ends. It is a sign of fetal hypoxia due to placental insufficiency.
Hemodynamic Instability (혈역학적 불안정) — A condition where the heart fails to supply enough blood to the body. This presents with low blood pressure and rapid heart rate, suggesting hypovolemic shock due to bleeding.
Emergency Cesarean Delivery (응급 제왕절개 분만) — A surgical delivery performed as quickly as possible when the life of the mother or fetus is threatened. It is the standard treatment in emergencies such as placental abruption.
Large-bore IV Access (굵은 정맥로 확보) — Securing intravenous access using a large-bore catheter, such as a 14-gauge or 16-gauge. This is essential for rapidly infusing large volumes of fluids or blood products to correct hypovolemia.