A nurse is caring for a 28-year-old primigravida who experienced a complete uterine inversion immediately after delivery of the placenta. The client is experiencing severe hemorrhage and shock, with vital signs: BP 80/50 mmHg, HR 130 bpm, respirations 28/min. She appears pale, diaphoretic, and reports severe pelvic pain and feeling faint. What is the nurse's priority action?
1Immediately attempt to manually replace the inverted uterus
2Administer prescribed oxytocin to stimulate uterine contractions
3Place the client in Trendelenburg position and apply fundal pressure
4Establish large-bore IV access and prepare for emergency surgery✓ 정답
해설
Complete uterine inversion with severe hemorrhage and shock requires immediate hemodynamic stabilization via large-bore IV access and preparation for emergency surgery. Manual replacement, oxytocin, and Trendelenburg with fundal pressure are contraindicated as they can worsen bleeding or cause further injury.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing action for a life-threatening postpartum complication: Uterine inversion. This is a rare but catastrophic obstetric emergency where the uterus turns inside out, often after delivery of the placenta. The primary dangers are profound hemorrhage from the exposed uterine lining and neurogenic shock due to traction on pelvic ligaments and peritoneum. The patient's vital signs (BP 80/50 mmHg, HR 130 bpm) and symptoms (pallor, diaphoresis, feeling faint) indicate Key Point!hypovolemic and neurogenic shock, making hemodynamic stabilization the absolute priority.
Answer Rationale: The correct answer is to Establish large-bore IV access and prepare for emergency surgery. This is the foundational ABC (Airway, Breathing, Circulation) and primary survey approach. Key Point! In a state of shock, the nurse's first role is to support circulation by establishing rapid fluid resuscitation pathways (two large-bore IVs) to replace lost volume. Simultaneously, preparing for surgery is critical because definitive treatment for a complete inversion often requires surgical intervention (e.g., manual replacement under anesthesia or a laparotomy) to correct the inversion and control bleeding. This action addresses the immediate threat to life.
Distractor Analysis:
Option 1 (Manually replace the uterus): Watch out for confusion! While manual replacement is a definitive treatment, it is not the nurse's independent action in this scenario. Attempting manual replacement without proper analgesia, anesthesia, and potentially tocolytic drugs (to relax the uterus) can cause severe pain, worsen shock, and lead to further tissue injury or hemorrhage. This is a physician/advanced practitioner procedure.
Option 2 (Administer oxytocin): This is contraindicated. Oxytocin causes uterine contraction. If the uterus is inverted and contracted down, administering oxytocin will tighten the cervical "ring" around the inverted fundus, trapping it and making reduction impossible. It can exacerbate the patient's condition.
Option 3 (Trendelenburg and fundal pressure): This is dangerous and contraindicated. The Trendelenburg position (head down) does not improve shock in hemorrhagic cases and can impair respiratory function. Applying fundal pressure to an inverted uterus is absolutely wrong—it will drive the already inverted fundus further down, worsening the inversion and potentially causing uterine rupture or further hemorrhage.
Related Concepts: This emergency integrates knowledge of postpartum hemorrhage (PPH) management, shock protocols, and the specific pathophysiology of uterine inversion. Management follows a sequence: stabilize the patient (IV access, fluids, blood products), then treat the cause (often in the operating room).Nursing Clinical Practice GuideClinical Scenario: You are the nurse in a Labor & Delivery unit. A patient who just delivered her placenta suddenly screams in severe pain, and you note a large amount of bright red blood on the bed. A globular mass is visible at the vaginal introitus. The patient becomes pale, sweaty, and her blood pressure drops.
Nursing Intervention Strategy:
Immediate Actions (Within seconds): Call for help using the emergency bell/code. Do NOT pull on the umbilical cord if still attached. Initiate your facility's massive transfusion protocol (MTP) if available.
Assessment & Monitoring: Continuously monitor vital signs, oxygen saturation, and level of consciousness. Assess estimated blood loss (weigh chux pads). Stay with the patient to provide reassurance and monitor for deterioration.
Collaborative Care: While you establish IV access, other team members will:
Administer high-flow oxygen via non-rebreather mask.
Draw labs (CBC, coagulation panel, type and crossmatch).
Prepare rapid infusion of warmed isotonic crystalloids (e.g., Normal Saline or Lactated Ringer's).
Prepare blood products (packed red blood cells, fresh frozen plasma) as ordered.
Assist the physician with preparations for manual replacement or transfer to the operating room.
Patient Safety and Precautions: Never attempt to replace the uterus or administer uterotonics like oxytocin, methylergonovine, or carboprost before the inversion is corrected. Keep the patient NPO (nothing by mouth) in anticipation of surgery. Handle the exposed uterine tissue gently if covered with sterile saline-soaked gauze (per protocol) to prevent trauma.
Goal: Establish two large-bore (14- or 16-gauge) IV lines in large peripheral veins (e.g., antecubital).
Infuse isotonic crystalloids wide open initially to restore intravascular volume.
Transition to blood products as soon as available. Use a rapid infuser or pressure bag if needed.
Monitor for signs of fluid overload (crackles in lungs, increased respiratory rate) once the patient stabilizes.
Medication Precautions:
Tocolytics (e.g., Terbutaline, Nitroglycerin): May be administered by the physician before attempting manual reduction to relax the cervical ring.
Uterotonics (e.g., Oxytocin): Are only given after the uterus is successfully replaced to promote contraction and prevent re-inversion or further hemorrhage.
A Word from Your Senior Nurse
"Uterine inversion is one of those 'never event' emergencies that requires you to override any routine postpartum nursing reflex. The instinct to massage the fundus or give Pitocin (oxytocin) must be suppressed immediately. Your brain needs to switch to trauma-mode: massive bleeding + shock = big IVs, lots of fluids, and get to the OR. Staying calm, knowing your protocols, and acting as the coordinator between the patient, the doctor, and the lab/blood bank is what saves lives. On the NCLEX, they love to test if you know the 'why' behind the contraindications—so remember, a contracted uterus is the enemy when it's inside out!"
Uterine Inversion — A rare, life-threatening obstetric emergency where the uterus turns inside out, usually following placental delivery. It causes profound hemorrhage and neurogenic shock.
Hypovolemic Shock — A state of circulatory collapse due to significant loss of blood or fluid volume, leading to inadequate tissue perfusion. Manifested by hypotension, tachycardia, pallor, and altered mental status.
Neurogenic Shock — A distributive shock caused by the loss of sympathetic tone, often from spinal cord injury or, in this context, traction on pelvic structures. Can contribute to hypotension and bradycardia (though often masked by hypovolemic tachycardia here).
Massive Transfusion Protocol — A standardized, pre-established hospital protocol for the rapid release and administration of blood products (PRBCs, FFP, platelets) in a specific ratio to treat life-threatening hemorrhage.
Tocolytic — A medication (e.g., terbutaline, nitroglycerin) used to relax uterine smooth muscle. Used in uterine inversion to relax the cervical ring before manual reduction attempts.