A 28-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 90/60 mmHg, pulse 110 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. The nurse is preparing for immediate surgical intervention. What is the priority nursing action?
1Administer prescribed analgesics for pain management
2Establish large-bore IV access and prepare for fluid resuscitation✓ 정답
3Position the patient in Trendelenburg position
4Obtain informed consent for surgical procedure
해설
This patient shows signs of a ruptured ectopic pregnancy with hemorrhage (hypotension, tachycardia, free fluid). The priority is establishing large-bore IV access for fluid resuscitation to prevent hypovolemic shock, as it addresses the immediate life-threatening circulatory compromise.
Clinical Context and Pathophysiology
This patient presents with a classic triad of ectopic pregnancy: amenorrhea (last menstrual period 7 weeks ago), unilateral lower abdominal pain, and vaginal spotting. The transvaginal ultrasound findings confirm a ruptured left tubal ectopic pregnancy — the uterus is empty, a 3.5 cm mass is visualized in the left fallopian tube, and free fluid (blood) is noted in the pelvis. Her vital signs — BP 90/60 mmHg (hypotension) and pulse 110 bpm (tachycardia) — indicate she is already in hypovolemic shock from intra-abdominal hemorrhage. In ectopic pregnancy, the growing embryo erodes into maternal blood vessels as the fallopian tube stretches and eventually ruptures, leading to rapid, life-threatening blood loss into the peritoneal cavity. This is a maternal near-miss (MNM) situation — a severe acute maternal morbidity where the woman nearly dies but survives a life-threatening obstetric complication [1][4]. The immediate threat is not pain or the need for consent, but hemodynamic collapse from ongoing hemorrhage.
Priority Nursing Action and Rationale
The correct answer is Option 2: Establish large-bore IV access and prepare for fluid resuscitation. In the hierarchy of emergency management for hemorrhagic shock, restoring circulating volume to maintain organ perfusion is the immediate priority. A large-bore IV (18-gauge or larger) allows rapid infusion of isotonic crystalloids (e.g., Lactated Ringer’s or normal saline) and blood products. The goal is to stabilize the patient for the operating room; surgical intervention is the definitive treatment to stop the bleeding, but the patient must survive the transport to the OR. This aligns with the principle that cases of ectopic pregnancy presenting with hemodynamic instability require urgent intervention with simultaneous arrangement of transport and blood transfusion [3].
Analysis of Other Options
- Option 1 (Administer prescribed analgesics): Pain management is important but secondary. Narcotic analgesics can cause vasodilation and further drop blood pressure in an already hypotensive patient. Addressing pain before volume status is dangerous in shock.
- Option 3 (Position in Trendelenburg): The Trendelenburg position (head down, feet up) was historically used for shock but is no longer recommended. It does not improve cardiac output, can impair respiratory mechanics by pushing abdominal contents against the diaphragm, and may increase the risk of aspiration. The current standard is to keep the patient supine or in a modified left lateral tilt if pregnancy is advanced, but the priority is fluid volume.
- Option 4 (Obtain informed consent): While informed consent is legally and ethically required before surgery, it is not the nurse’s most immediate action in a life-threatening emergency. The surgeon typically obtains consent. The nurse’s priority is to participate in the resuscitation that keeps the patient alive long enough for consent and surgery to occur. Delaying fluid resuscitation to obtain a signature would worsen the patient’s outcome.
Clinical Reasoning and Evidence Integration
The acute abdomen, as seen here, is a life-threatening entity requiring immediate diagnostic evaluation and treatment; 15-20% of emergency patients with acute abdominal pain need urgent surgical or interventional treatment . In this case, the sudden onset of severe pain with hemodynamic instability and evidence of free fluid on ultrasound confirms a surgical emergency. The nurse’s role is to recognize the signs of shock and act on the ABCs (Airway, Breathing, Circulation). Circulation takes precedence here: large-bore IV access and aggressive fluid resuscitation are the foundational nursing interventions that bridge the patient to definitive surgical control of the hemorrhage. The study on maternal near-miss cases emphasizes that prompt, structured management of these life-threatening conditions is critical to preventing maternal death [1][4].
References (research sources)
[1]
A Prospective Observational Study of Maternal Near-Miss Cases at a Tertiary Care Center.Research articlePatil AS, Biradar AM, Sangolli L, Patil N, Bidri SR, Malapure P, Tippabhotla A, Umerjikar S, Amreen SA, Khavekar A. (2026) · DOI: 10.7759/cureus.105515
[3]
Uncommon Ectopic Pregnancies-Challenges in the Management.Research articleKonar H, Konar L, Konar C, Halder A, Saha A, Khamaru J. (2022) · DOI: 10.1007/s13224-021-01605-8
[4]
Maternal near miss in a teaching hospital in the Brazilian Midwest: contributions to care.Research articleSilveira AAD, Sales APA, Cardoso AIQ, Teston EF, Batiston AP, Medeiros RMK. (2025) · DOI: 10.1590/1980-220x-reeusp-2024-0200en
Clinical Practice Guide: Ruptured Ectopic Pregnancy with Hemorrhagic Shock
Scope: Emergency Department nursing management upon presentation of suspected ruptured ectopic pregnancy.
1. Immediate Recognition and Triage
Classic Triad: Amenorrhea, unilateral lower abdominal pain, and vaginal spotting. A high index of suspicion is required for any reproductive-age woman with these symptoms.
Shock Index: Calculate immediately. Heart rate (110 bpm) divided by systolic blood pressure (90 mmHg) equals 1.22. A value greater than 0.9 indicates hemodynamic instability and a high risk of massive transfusion.
Point-of-Care Ultrasound: Findings of an empty uterus, adnexal mass, and free fluid in the pelvis confirm the diagnosis and indicate rupture.
2. Priority Nursing Actions (First 5 Minutes)
Establish Large-Bore IV Access: Insert two 18-gauge or larger peripheral IV catheters, preferably in the antecubital fossae. This is the highest priority action to enable rapid volume infusion.
Initiate Fluid Resuscitation: Begin rapid bolus of warmed isotonic crystalloid (Lactated Ringer's or normal saline) using a pressure bag. The goal is to maintain a systolic BP of at least 90 mmHg and improve mentation. Activate the massive transfusion protocol if signs of class III or IV shock are present.
Collect and Send Labs: Draw blood for type and crossmatch (at least 4 units), complete blood count, and quantitative beta-hCG. Ensure the blood bank has an active sample.
Prepare for Surgery: Notify the OR team and obstetrician. Keep the patient NPO. The definitive treatment for a ruptured ectopic pregnancy is surgical intervention (laparotomy or laparoscopy).
3. Ongoing Monitoring and Reassessment
Vital Signs: Monitor every 5-15 minutes. Assess for trends indicating response to resuscitation (narrowing pulse pressure, decreasing heart rate, increasing blood pressure).
Level of Consciousness: A decline in mentation is a late and ominous sign of cerebral hypoperfusion.
Urine Output: Insert a Foley catheter to monitor output, targeting greater than 0.5 mL/kg/hr as a marker of adequate renal perfusion.
Blood Loss: Visually estimate external blood loss but recognize that the majority of hemorrhage is concealed within the peritoneal cavity.
4. Common Pitfalls to Avoid
Delaying Resuscitation for Diagnostic Certainty: Do not wait for a formal radiology report or lab results to begin fluid resuscitation if clinical signs of shock are present.
Using Vasopressors as First-Line Therapy: Vasopressors are not a substitute for volume replacement in hemorrhagic shock and may worsen tissue ischemia if used before adequate volume restoration.
Placing the Patient in Trendelenburg Position: This position does not improve cardiac output and may impair respiratory mechanics. Keep the patient supine with legs elevated only if it does not cause pain or impede IV access.
Assuming a Stable Patient Will Remain Stable: A contained tubal rupture can become a free rupture with catastrophic hemorrhage at any moment. Continuous monitoring and preparedness for immediate intervention are essential.
Ectopic Pregnancy — A pregnancy in which the fertilized egg implants outside the uterine cavity, most commonly in the fallopian tube, posing a risk of rupture and life-threatening hemorrhage.
Hypovolemic Shock — An emergency condition in which severe blood or fluid loss makes the heart unable to pump enough blood to the body, causing organ failure.
Large-Bore IV Access — Insertion of a short, wide intravenous catheter (18-gauge or larger) to allow for rapid administration of fluids and blood products during resuscitation.
Fluid Resuscitation — The initial management of shock involving rapid infusion of isotonic crystalloids or blood products to restore circulating volume and tissue perfusion.
Transvaginal Ultrasound — An imaging test using a probe inserted into the vagina to visualize the uterus, ovaries, and fallopian tubes, commonly used to diagnose ectopic pregnancy.