A 28-year-old woman presents to the emergency department with a 6-week history of amenorrhea, left lower abdominal pain, and vaginal spotting, and has become increasingly unstable over the past hour. Which assessment finding would be most indicative of a ruptured ectopic pregnancy?

A patient with a suspected ectopic pregnancy who becomes unstable requires immediate recognition of rupture signs. The classic triad is amenorrhea, unilateral abdominal pain, and vaginal spotting. The most critical assessment finding indicating rupture is the sudden onset of severe, sharp abdominal pain accompanied by referred shoulder pain, known as Kehr's sign. This sign reflects diaphragmatic irritation from intraperitoneal blood and demands emergency surgical intervention.

• Pain Characteristics: Sudden, severe, sharp, or stabbing unilateral lower quadrant pain. It is constant and not relieved by position changes.
• Kehr's Sign: Referred pain to the shoulder or supraclavicular area, indicating free blood in the peritoneal cavity irritating the diaphragm.
• Hemodynamic Instability: Tachycardia, hypotension, pallor, and dizziness progressing to shock from hypovolemia.
• Abdominal Assessment: Abdominal distension, rigidity, guarding, and rebound tenderness may be present.

1. Initiate rapid response or activate the emergency team.
2. Establish two large-bore IV lines and begin fluid resuscitation with crystalloids as prescribed.
3. Administer oxygen to maintain saturation above 94%.
4. Prepare for immediate blood transfusion and surgical intervention (laparotomy).
5. Place the patient in a supine position and continuously monitor vital signs and level of consciousness.

NCLEX-RN Alert: Kehr's sign is a high-yield, classic indicator of intraperitoneal bleeding. Do not confuse the gradual, nonspecific symptoms of an unruptured ectopic with the acute, dramatic presentation of a rupture.