A 25-year-old woman presents to the emergency department with severe left lower abdominal pain, vaginal spotting, and dizziness. Her last menstrual period was 7 weeks ago. Vital signs show BP 85/55 mmHg, HR 120 bpm, and temperature 98.6°F. Transvaginal ultrasound reveals an empty uterus and a 3.5 cm mass in the left fallopian tube with free fluid in the pelvis. What is the priority nursing intervention?
The patient appears pale and anxious, reporting that the pain started suddenly 2 hours ago and has been worsening. She denies any previous history of pelvic inflammatory disease or sexually transmitted infections but mentions she had fertility treatments 6 months ago.
1Administer prescribed analgesics for pain management
2Obtain a complete obstetric history and perform a pelvic examination
3Prepare the patient for immediate blood transfusion
4Establish large-bore IV access and prepare for emergency surgery✓ 정답
해설
Priority is establishing large-bore IV access and preparing for emergency surgery due to signs of ruptured ectopic pregnancy with hemorrhage (hypotension, tachycardia, free fluid). Pain management and history are less urgent.
The patient presents with the classic triad of ectopic pregnancy: amenorrhea (last menstrual period 7 weeks ago), unilateral lower abdominal pain, and vaginal spotting. Her vital signs—BP 85/55 mmHg and HR 120 bpm—indicate hypovolemic shock secondary to tubal rupture. The transvaginal ultrasound confirms this, showing an empty uterus, a left adnexal mass, and free pelvic fluid, which represents intraperitoneal hemorrhage. The sudden onset of severe pain 2 hours ago, followed by worsening symptoms and signs of poor perfusion (pallor, dizziness), signals that rupture has already occurred and bleeding is ongoing.
Pathophysiology of Hypovolemic Shock in Ectopic Pregnancy
When the trophoblast implants in the fallopian tube, it invades the tubal wall, which lacks the thick, distensible myometrium of the uterus. As the pregnancy grows, the tube stretches and eventually ruptures, causing hemorrhage into the peritoneal cavity. This rapid blood loss reduces circulating volume, decreasing venous return to the heart, which lowers cardiac output and tissue perfusion. The body attempts to compensate through sympathetic activation, producing tachycardia and vasoconstriction. However, once compensatory mechanisms fail, hypotension develops—a late and ominous sign indicating that blood loss is approaching 30-40% of total volume.
Priority Nursing Intervention: Rationale
The correct answer is Option 4: Establish large-bore IV access and prepare for emergency surgery. In hypovolemic shock from ruptured ectopic pregnancy, the definitive treatment is surgical intervention to stop the hemorrhage. Fluid resuscitation is a critical temporizing measure that nurses initiate, but it cannot replace the lost red blood cell mass or halt the ongoing bleeding. According to the evidence synthesis on fluid resuscitation in hypovolemic shock, nurses play a central role in early recognition, timely intervention, and continuous monitoring . Establishing large-bore intravenous access (at least 18-gauge, preferably two lines) allows for rapid infusion of crystalloids or blood products to restore intravascular volume while the surgical team is mobilized. Simultaneous preparation for surgery addresses the root cause—the ruptured tube—without which resuscitation efforts will ultimately fail.
Analysis of Incorrect Options
Option 1 (Administer prescribed analgesics) is inappropriate as a priority. While pain management is an important nursing responsibility, administering opioids in a hemodynamically unstable patient can worsen hypotension through vasodilation and mask clinical deterioration. Pain control should occur only after resuscitation is underway and the patient is stabilized.
Option 2 (Obtain complete obstetric history and perform pelvic examination) delays life-saving intervention. A thorough history is valuable but must not take precedence over stabilization. Additionally, a bimanual pelvic examination is contraindicated when ectopic rupture is suspected, as manipulation can precipitate further hemorrhage.
Option 3 (Prepare for immediate blood transfusion) is partially correct but incomplete. Blood transfusion addresses volume and oxygen-carrying capacity deficits, and type and crossmatch should be sent. However, transfusing without simultaneously preparing for surgery does not stop the source of bleeding. The nurse's priority is to facilitate both volume resuscitation and definitive surgical management, which is best accomplished by establishing IV access and readying the patient for the operating room.
Nursing Implications for Emergency Care
The evidence emphasizes that prompt fluid resuscitation is critical in hypovolemic shock, with nurses serving as the frontline clinicians who recognize deterioration, initiate protocols, and monitor response . In this scenario, the nurse must immediately place the patient in a supine position, administer high-flow oxygen, insert two large-bore IVs, begin warmed crystalloid infusion, send blood for type and crossmatch, insert a Foley catheter to monitor urine output, and notify the surgical team. Continuous reassessment of vital signs, level of consciousness, and urine output guides ongoing resuscitation. The goal is to maintain a mean arterial pressure adequate for organ perfusion while expediting transfer to the operating room for salpingostomy or salpingectomy.
Clinical Practice Guide: Ruptured Ectopic Pregnancy
Shock Indicators: Hypotension (BP 85/55 mmHg), tachycardia (HR 120 bpm), pallor, and dizziness suggest significant blood loss (often 30-40% of total volume).
Diagnostic Confirmation: Transvaginal ultrasound showing an empty uterus, an adnexal mass (3.5 cm), and free pelvic fluid confirms tubal rupture and intraperitoneal hemorrhage.
Immediate Nursing Priorities
Establish Large-Bore IV Access: Insert two large-bore (14-18 gauge) intravenous catheters in the antecubital or forearm veins. Initiate rapid infusion of warmed crystalloid solutions (e.g., Lactated Ringer's or 0.9% Normal Saline) to restore circulating volume.
Prepare for Emergency Surgery: Notify the surgical team and operating room immediately. Obtain informed consent. Prepare the patient for laparoscopy or laparotomy (NPO status, surgical site preparation, removal of jewelry).
Continuous Monitoring: Assess vital signs every 5-15 minutes, monitor oxygen saturation, and observe for signs of worsening shock (e.g., altered mental status, decreased urine output).
Supportive Interventions
Oxygen Therapy: Apply high-flow oxygen via a non-rebreather mask to maximize tissue oxygenation.
Trendelenburg Position: Place the patient in a modified Trendelenburg position (supine with legs elevated) to promote venous return, unless contraindicated.
Blood Products: Prepare for type and crossmatch, and anticipate the need for packed red blood cells or massive transfusion protocol if hemodynamic instability persists after fluid resuscitation.
Emotional Support: Provide clear, calm explanations to the patient and family, acknowledging the emotional impact of pregnancy loss and the urgency of the situation.
Rationale for Delaying Other Actions
Pain Management: Opioids can cause vasodilation and worsen hypotension; administer only after fluid resuscitation has begun and per provider order.
Detailed History/Pelvic Exam: A complete history and bimanual exam are contraindicated as they delay definitive care and may aggravate hemorrhage. The ultrasound already provides a diagnosis.
Blood Transfusion Alone: Transfusion is a component of resuscitation but cannot stop the surgical hemorrhage; IV access must precede administration, and surgery is the definitive treatment.
Ectopic Pregnancy — A pregnancy implanted outside the uterine cavity, most commonly in the fallopian tube, which can rupture and cause life-threatening intraperitoneal hemorrhage.
Hypovolemic Shock — A critical condition resulting from significant blood or fluid loss, leading to inadequate tissue perfusion, characterized by tachycardia, hypotension, and altered mental status.
Large-bore IV access — Insertion of a short, wide-diameter intravenous catheter (e.g., 14-18 gauge) to facilitate rapid infusion of large volumes of crystalloid fluids or blood products during resuscitation.
Transvaginal Ultrasound — An imaging technique using a probe inserted into the vagina to visualize pelvic structures, essential for diagnosing ectopic pregnancy by identifying an empty uterus with an adnexal mass.