A postpartum client on the second day after cesarean delivery suddenly develops chest pain, shortness of breath, and anxiety. Vital signs are: BP 90/60 mmHg, HR 120 bpm, RR 28/min, O2 sat 88% on room air. The nurse suspects pulmonary embolism. What is the priority nursing action?
1Administer prescribed analgesics for chest pain relief
2Encourage deep breathing and coughing exercises
3Position the client in Trendelenburg position
4Apply high-flow oxygen and prepare for emergency interventions✓ 정답
해설
Pulmonary embolism is a life-threatening emergency requiring immediate oxygenation and preparation for emergency interventions. Administering high-flow oxygen addresses hypoxemia, while other options are less urgent or inappropriate.
This question tests your ability to recognize an acute pulmonary embolism (PE) in a high-risk postpartum client and identify the priority nursing action based on the ABC (Airway-Breathing-Circulation) framework. Post-cesarean clients are at elevated risk for thromboembolic events due to venous stasis, vessel injury during surgery, and the hypercoagulable state of pregnancy extending into the postpartum period.
The client's presentation — sudden onset chest pain, dyspnea, anxiety, hypotension (BP 90/60 mmHg), tachycardia (HR 120 bpm), tachypnea (RR 28/min), and significant hypoxemia (O2 sat 88%) — indicates a massive or high-risk pulmonary embolism with hemodynamic instability. Acute PE is a critical emergency condition that can lead to rapid hemodynamic compromise and death if not treated promptly [1].
Analysis of Each Option
Option 1: Administer prescribed analgesics for chest pain relief.
While chest pain management is a comfort measure, it does not address the life-threatening hypoxemia and hemodynamic instability. In the prioritization hierarchy, physiological needs related to oxygenation and circulation take precedence over pain. Administering opioids could further depress respiratory drive, worsening the client's already compromised status.
Option 2: Encourage deep breathing and coughing exercises.
Deep breathing and coughing are preventive measures for atelectasis and pneumonia, not therapeutic interventions for an active pulmonary embolism. In massive PE, the primary problem is a ventilation-perfusion (V/Q) mismatch caused by vascular obstruction, not retained secretions. This intervention would be ineffective and delays critical care.
Option 3: Position the client in Trendelenburg position.
The Trendelenburg position (head lower than feet) was historically used for shock but is contraindicated in massive PE. This position increases venous return to an already strained right ventricle, potentially worsening right ventricular failure. It also increases intracranial pressure and impairs respiratory excursion by pushing abdominal contents against the diaphragm, further compromising oxygenation in a client already at O2 sat 88%.
Option 4: Apply high-flow oxygen and prepare for emergency interventions. (CORRECT)
This is the priority action. The client demonstrates severe hypoxemia (O2 sat 88%) and signs of obstructive shock (BP 90/60 mmHg, HR 120 bpm). Immediate high-flow oxygen addresses the critical breathing deficit and supports tissue oxygenation while the nurse simultaneously prepares for definitive emergency interventions, including rapid notification of the provider and preparation for anticoagulation therapy.
Why Early Anticoagulation Matters
The provided research emphasizes that acute PE requires prompt treatment to prevent hemodynamic deterioration and death. The study specifically assessed whether initiating anticoagulation within two hours of emergency department presentation improves outcomes [1]. In the clinical setting, the nurse's role is to:
1. Stabilize oxygenation first — applying high-flow oxygen to correct hypoxemia.
2. Facilitate rapid diagnosis and treatment — preparing for diagnostic studies (CT pulmonary angiography) and ensuring timely administration of anticoagulation as prescribed.
The research supports that early therapeutic intervention is critical for survival in acute PE [1]. The nurse's immediate actions of oxygen application and preparation for emergency interventions directly align with this evidence, as delays in initiating appropriate therapy can result in worsening right ventricular strain, cardiogenic shock, and cardiac arrest.
NCLEX Priority-Setting Framework
This question applies Maslow's Hierarchy of Needs and the ABC priority-setting framework. Oxygenation is the most fundamental physiological need. Without adequate oxygen delivery, all other interventions become futile. The client's O2 sat 88% represents an immediate threat to life that must be corrected before addressing comfort (pain), promoting ineffective preventive measures (coughing/deep breathing), or implementing potentially harmful positioning (Trendelenburg).
References (research sources)
[1]
The Effect of Early Anticoagulation Therapy in Acute Pulmonary Embolism: A Retrospective Cohort Study in the Emergency Department.Research articleRiaz A, Fatima N, Ali Q, Kazi N, Khalid S, Khalid Ranjha HU, Almagharbeh WT, Obazenu LO. (2026) · DOI: 10.7759/cureus.100980
Clinical Practice Guide: Emergency Response to Postpartum Pulmonary Embolism
Immediate Recognition and Assessment
Promptly identify the classic triad of sudden-onset pleuritic chest pain, unexplained dyspnea, and tachypnea in a postpartum patient, particularly after cesarean delivery. Be vigilant for signs of massive PE, which include hemodynamic instability (systolic BP < 90 mmHg or a drop of > 40 mmHg from baseline) and severe hypoxemia. A high index of suspicion is critical due to the hypercoagulable state of the puerperium.
Priority Nursing Actions (ABC Framework)
Breathing and Oxygenation: Immediately apply high-flow oxygen (e.g., 10-15 L/min via a non-rebreather mask) to target an oxygen saturation > 94%. Prepare for advanced airway management if the patient exhibits severe respiratory distress, altered mental status, or refractory hypoxemia.
Circulation Support: Establish two large-bore intravenous (IV) lines. Administer IV fluids cautiously, typically 500 mL boluses of isotonic crystalloid, to support preload without causing right ventricular overload. Prepare for vasopressor therapy if hypotension persists despite fluid resuscitation.
Emergency Interventions: Notify the Rapid Response Team and the primary provider immediately. Prepare the patient for emergent diagnostic testing, such as a CT pulmonary angiography (CTPA) if stable enough for transport, or bedside echocardiography to assess for right ventricular strain. Anticipate the administration of systemic anticoagulation (e.g., unfractionated heparin bolus and infusion) or, in massive PE with shock, the activation of the thrombolysis or surgical embolectomy protocol.
Nursing Considerations and Monitoring
Maintain strict bed rest with the head of the bed elevated to 30-45 degrees to optimize ventilation. Continuously monitor cardiac rhythm, vital signs, and pulse oximetry. Avoid any actions that increase venous stasis or intrathoracic pressure, such as the Valsalva maneuver. Provide clear, calm explanations to the patient and family to reduce anxiety, which can exacerbate dyspnea and tachycardia. Document all assessments, interventions, and the patient's response in real-time.
Pulmonary Embolism — A blockage in one of the pulmonary arteries in the lungs, often caused by blood clots that travel from the legs or other parts of the body, leading to impaired gas exchange and hemodynamic compromise.
ABC Priority Framework — A systematic approach to nursing prioritization that addresses Airway, Breathing, and Circulation first, as these are essential for immediate survival.
High-Risk Postpartum — The period after childbirth characterized by venous stasis, vessel injury, and a hypercoagulable state, significantly increasing the risk for thromboembolic events.
Hypoxemia — An abnormally low concentration of oxygen in the arterial blood, indicated here by an oxygen saturation of 88% on room air.
Hemodynamic Instability — A state of abnormal blood flow dynamics, evidenced by hypotension and tachycardia, indicating the heart and circulation are failing to perfuse tissues adequately.