A 32-year-old gravida 3, para 2 woman at 12 weeks gestation presents to the emergency department with severe cramping that started 2 hours ago and heavy vaginal bleeding with clots. The cervical os is open, and fetal tissue is visible. What is the priority nursing intervention?
A 28-year-old gravida 2, para 1 woman at 12 weeks gestation arrives at the emergency department reporting severe abdominal cramping that started 2 hours ago, accompanied by heavy vaginal bleeding with clots.
1Administer pain medication as ordered
2Prepare the patient for immediate surgery
3Obtain vital signs and assess for signs of shock
4Save all tissue and clots for pathological examination✓ 정답
해설
In inevitable abortion with an open cervix and visible fetal tissue, saving all tissue and clots for pathological examination is the priority to confirm diagnosis and ensure complete evacuation. Other interventions are secondary as they do not address the need for diagnostic confirmation.
Clinical Judgment
This question assesses the priority nursing intervention in a situation of Inevitable Abortion. The key clues are "cervical os is open" and "fetal tissue is visible." This means the miscarriage is in progress and cannot be reversed. The most important action in this situation is securing evidence to confirm the diagnosis and establish a subsequent treatment plan. Preserving all tissue and clots is essential to evaluate whether the abortion is complete or incomplete, and to assess the cause of the miscarriage (e.g., genetic abnormalities). Measuring vital signs (option 3) is an important secondary intervention, but at this moment when tissue is already being expelled, securing the tissue—which could be permanently lost if not collected—is a more urgent priority as it provides crucial evidence.
Memory Tip: A mnemonic to remember the priority in inevitable abortion: Save the Tissue First! (STF). Preserve the tissue first! Vital signs come next.
KR vs US: In Korea, it is common to send tissue for pathological examination during a miscarriage, but there may be a culture of focusing more immediately on vital signs and shock assessment during the initial emergency room evaluation. In NGN/US exams, the action for evidence-based accurate diagnosis (tissue preservation) is considered the priority when an immediate life threat is not obvious (e.g., vital signs have not yet been measured, but the patient does not appear to be in massive hemorrhage).
Clinical Practice Guide
When caring for a patient being evaluated for an inevitable/incomplete abortion:
1. Handle all expelled tissue aseptically and send it immediately to pathology in saline-moistened gauze or a container.
2. Measure vital signs simultaneously with or immediately after tissue collection, and assess for signs of hemorrhagic shock such as syncope, pallor, tachycardia, and hypotension.
3. Securing IV access, fluid administration, blood type testing, and crossmatch preparation are part of the standard protocol.
Caution: In SATA (Select All That Apply) questions, both "preserve all tissue" and "measure vital signs/assess for shock" may appear as options. In this case, you must read the context of the situation. Phrases like "when the patient arrives (first action)" or "when tissue is visible (priority)" prioritize tissue preservation. For questions focused on "patient assessment," measuring vital signs may be more appropriate.
Inevitable Abortion — Inevitable abortion. The cervix is opening (cervical os dilation), there is bleeding and cramping, and the pregnancy cannot be maintained. The miscarriage is in progress.
Incomplete Abortion — Incomplete miscarriage. A condition where some pregnancy products remain inside the uterus. There is a risk of persistent bleeding and infection.
Products of Conception — Products of conception. A term encompassing all tissues formed during pregnancy, including fetal tissue, placenta, and amniotic membranes. Subject of pathological examination.
Dilation and Curettage (D&C) — Cervical dilation and curettage. A surgical procedure performed to remove retained tissue after an incomplete miscarriage or for diagnostic purposes.
Hemorrhagic Shock — Hemorrhagic shock. A state of inadequate tissue perfusion due to massive blood loss. Symptoms include tachycardia, hypotension, pallor, cold and clammy skin, and decreased level of consciousness.