A 32-year-old gravida 2, para 1 client at 34 weeks gestation presents to the labor and delivery unit with sudden onset of severe abdominal pain and vaginal bleeding. Assessment reveals a rigid, board-like abdomen, fetal heart rate of 90 bpm with minimal variability, and maternal vital signs: BP 90/60 mmHg, HR 120 bpm, RR 24/min. Ultrasound confirms complete placental abruption. What is the priority nursing intervention?
1Administer oxygen via nasal cannula at 2-4 L/min
2Insert two large-bore IV catheters and initiate fluid resuscitation
3Position the client in left lateral position to improve placental perfusion
4Prepare for immediate cesarean delivery and notify the surgical team✓ 정답
해설
Complete placental abruption is an obstetric emergency requiring immediate cesarean delivery to prevent maternal hemorrhage and fetal demise. Supportive measures like oxygen or IV fluids are secondary to surgical intervention.
Clinical Judgment
This question tests Prioritization and Clinical Judgment. The core is identifying the most critical and immediate treatment among several necessary interventions in a life-threatening emergency of "Complete Placental Abruption." The patient's condition, with fetal bradycardia (90 bpm) and maternal hypotension, puts both mother and fetus at risk. In this case, supportive interventions (oxygen, fluids, positioning) are important but do not address the root cause of the bleeding and hypoxia (the detached placenta). The only cure is immediate delivery to remove the fetus and contract the uterus to stop the bleeding. Therefore, notifying the surgical team and preparing for a cesarean section is the top life-saving priority action.
Memory TipAbruption = Action NOW! or Delivery is the Definitive therapy for complete Detachment.
KR vs US
In Korea, when placental abruption occurs, a conservative approach of stabilizing the mother, monitoring the fetus, and attempting vaginal delivery if possible may be more common. However, from the US NGN/NCLEX perspective, when there are clear life-threatening signs as presented (complete abruption, fetal bradycardia, maternal hypotension), immediate cesarean section is the standard treatment protocol, and the nurse's priority is to prepare for it. Just like 'Time is muscle,' here, 'Time is life.'
Clinical Practice GuideManagement of Complete Placental Abruption (Class 3 Abruption): 1) Notify HCP! and activate the emergency response team. 2) Continuously monitor maternal and fetal status. 3) Prepare for massive transfusion protocol. 4) Prepare the operating room for emergency cesarean section.CautionA common pitfall in SATA (Select All That Apply) questions is that "all interventions are important." Administering oxygen, securing intravenous access, and lateral positioning are all correct interventions, but in this specific scenario, the single highest priority intervention is the action that enables definitive treatment (delivery). "Prepare and notify" is often the correct answer.
Placental Abruption (태반조기박리) — A condition where the placenta partially or completely separates from the uterine wall before delivery. An emergency situation that can cause maternal bleeding, fetal hypoxia, and uterine rigidity.
Cesarean Delivery (제왕절개술) — Surgical delivery of the fetus through an incision in the abdomen and uterus. Performed as an emergency when there is risk to the mother or fetus, such as placental abruption or fetal distress.
Hypovolemic Shock (저혈량성 쇼크) — A condition where tissue perfusion becomes insufficient due to a rapid decrease in circulating blood volume. A major complication of massive hemorrhage caused by placental abruption.
Uterine Atony (자궁무력증) — A condition where the uterus fails to contract properly after childbirth. A factor that can further increase the risk of bleeding after premature placental abruption. (In this case, preventive management is important)