A nurse is caring for a laboring client who suddenly develops severe abdominal pain, cessation of contractions, and signs of shock. The fetal heart rate shows bradycardia with loss of variability. Which nursing intervention should be the immediate priority?
1Administer oxygen via face mask at 8-10 L/min
2Insert a large-bore IV catheter and begin fluid resuscitation
3Prepare the client for immediate cesarean delivery✓ 정답
4Position the client in Trendelenburg position
해설
Uterine rupture requires immediate cesarean delivery to control hemorrhage and deliver the fetus. Supportive measures like oxygen and IV fluids are secondary to surgical intervention.
Core Nursing ExplanationKey Concept Analysis: This question describes a classic, life-threatening obstetric emergency: Uterine rupture. The scenario includes the "triad" of signs: 1) Sudden, severe abdominal pain, 2) Cessation of uterine contractions, and 3) Maternal shock (e.g., tachycardia, hypotension) with fetal distress (bradycardia, loss of variability). The pathophysiology involves a tear in the uterine wall, leading to massive intra-abdominal hemorrhage, fetal compromise, and potential maternal exsanguination.
Answer Rationale: Key Point! In uterine rupture, the priority nursing intervention is to facilitate immediate surgical delivery (cesarean section). This is the only definitive treatment to stop the hemorrhage (by repairing or removing the uterus) and rescue the fetus from a hostile, anoxic environment. Every minute of delay increases mortality for both mother and baby. While supportive measures are critical, they are secondary to getting the patient to the operating room.
Distractor Analysis:
① Administering oxygen is a correct supportive action for maternal and fetal hypoxia but does not address the source of the problem—the ruptured uterus and ongoing hemorrhage.
② Inserting a large-bore IV and beginning fluid resuscitation is an essential component of managing hypovolemic shock. However, in this critical scenario, it should be initiated rapidly while simultaneously preparing for surgery. The nurse's priority action is to activate the emergency response to get the patient to surgery.
④ Positioning in Trendelenburg (head down) is Watch out for confusion! generally contraindicated in shock and especially in a pregnant patient. It can impair respiratory function by increasing pressure on the diaphragm and does not effectively improve cerebral perfusion. The preferred position for shock in pregnancy is left lateral tilt to relieve aortocaval compression.
Related Concepts: This scenario tests the ABC (Airway, Breathing, Circulation) principle in an obstetric context, where the "C" (Circulation) is compromised by a surgical cause requiring immediate operative control. It also integrates knowledge of fetal monitoring (interpretation of bradycardia and loss of variability as ominous signs) and the nursing role in recognizing and responding to emergencies.
Concept Summary
Concept
Key Points
Uterine Rupture
Complete tear through uterine wall. Medical emergency. Classic signs: Sudden pain, contraction cessation, shock, fetal distress.
Fetal Heart Rate (FHR) Patterns
Bradycardia (FHR < 110 bpm) with loss of variability indicates severe fetal compromise/acidosis.
Maternal Shock in Obstetrics
Often hypovolemic from hemorrhage. Manage with IV fluids/blood but identify and treat the source (e.g., surgery for rupture, manual removal for placenta accreta).
Nursing Priority in Emergencies
Definitive treatment (surgery) takes precedence over supportive care when the cause is surgical/obstructive.
Side-by-Side Comparison!
Obstetric Emergency
Key Differentiating Signs
Immediate Nursing Priority
Uterine Rupture
Sudden tearing pain, loss of contractions, maternal shock, fetal bradycardia.
Visible/palpable cord in vagina after ROM (Rupture Of Membranes), variable or prolonged decelerations in FHR.
Relieve cord compression (e.g., knee-chest position, manual elevation of presenting part), prepare for emergency cesarean.
Amniotic Fluid Embolism (AFE)
Sudden dyspnea, cyanosis, cardiovascular collapse, coagulopathy, often during/after delivery.
Cardiopulmonary resuscitation (CPR), advanced cardiac life support (ACLS), supportive ICU care.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Uterine rupture causes hemorrhage into the peritoneal cavity. This leads to hypovolemic shock (decreased preload → decreased cardiac output → hypotension, tachycardia) and reduced uteroplacental perfusion, causing fetal hypoxia and acidosis (manifesting as bradycardia).
Risk Factors: Previous cesarean section or uterine surgery, grand multiparity, overdistention (twins, polyhydramnios), prolonged labor with oxytocin (Pitocin) augmentation.
Pharmacology Context:
Oxytocin (Pitocin): Used to induce/augment labor. Excessive doses or use in an obstructed labor can lead to uterine hyperstimulation and increase rupture risk.
Tocolytics (e.g., Terbutaline): May be used to relax the uterus in cases of suspected impending rupture, but definitive treatment is surgical.
Memory Tips
Acronym for Uterine Rupture Signs: R.U.P.T.U.R.E R - Rapid maternal heart rate (tachycardia)
U - Uterine pain (sudden, severe)
P - Pressure drop (hypotension)
T - Tear felt (sometimes described by patient)
U - Uterine contour change (palpable defect)
R - Resting tone (contractions cease)
E - Emergency! (Fetal distress - bradycardia)
Priority Mnemonic: In OB hemorrhage emergencies, think "Source, Support, Surgery". Identify and treat the SOURCE first (which often requires SURGERY), while providing SUPPORT (O2, IV fluids).
High-Frequency NCLEX Topics
The NCLEX-RN heavily tests prioritization in emergency situations. Uterine rupture is a classic "priority action" question. Remember: When the question describes a scenario where both mother and fetus are in immediate, life-threatening danger due to a surgical cause, the answer that leads to definitive surgical intervention (e.g., "prepare for cesarean delivery," "notify the surgeon immediately") is almost always the priority over preparatory or supportive nursing actions.
Watch Out for Question Variations!
Symptom Identification: "A client with a previous cesarean section reports a 'ripping' sensation during labor. The nurse should assess for which signs first?" (Ans: Check for cessation of contractions, maternal vital signs, and FHR pattern).
Postpartum Complication: "Following a difficult vaginal delivery, a client exhibits signs of shock. The fundus is firm. What should the nurse suspect?" (Ans: This points away from uterine atony and toward concealed hemorrhage like a broad ligament hematoma or uterine rupture).
Medication Question: "The nurse is administering oxytocin for labor augmentation. Which finding requires immediate discontinuation of the infusion?" (Ans: Signs of uterine hyperstimulation or fetal distress, which are precursors to complications like rupture).
Nursing Clinical Practice GuideClinical Scenario: You are the labor and delivery nurse for Maria, a G3P2 at 39 weeks with a history of one prior low-transverse cesarean section (CS) attempting a Vaginal Birth After Cesarean (VBAC). She has been in active labor for 10 hours. Suddenly, she screams in pain, clutching her abdomen, and states, "It feels like something ripped!" You note her contractions on the tocometer have stopped. Her blood pressure is 82/50 mmHg and heart rate is 128 bpm. The external fetal monitor shows a fetal heart rate of 80 bpm with minimal variability.Nursing Intervention Strategy:
1Immediate Action (Seconds)Stay with the client. Call out for help using the emergency call system. Do NOT leave the client. Manually check the FHR via Doppler if external monitor is questionable, but do not delay.
2Activation (Within 1 Minute)Verbally alert the charge nurse, obstetrician, anesthesiologist, and neonatal resuscitation team. State clearly: "Possible uterine rupture in Room 3, maternal shock, fetal bradycardia. Need OR stat."
3Concurrent Supportive Measures (En Route to OR)* Positioning: Place client in left lateral position if possible to optimize venous return, but preparation for rapid transfer is key.
* Oxygen: Apply non-rebreather mask at 10-15 L/min.
* IV Access: If not already present, insert a second large-bore (16- or 18-gauge) IV catheter. Begin rapid infusion of isotonic crystalloid (e.g., Lactated Ringer's or Normal Saline) wide open.
* Monitoring: Continuously monitor vital signs and FHR until the moment of surgical incision.
4PreparationEnsure the informed consent for surgery is obtained (by the physician) if not already on file. Gather and send all relevant records (prenatal chart, labor flow sheet) to the OR. Facilitate the rapid transfer of the client to the operating room.
Patient Safety and Precautions:
* Contraindication: Do not attempt a vaginal exam if cord prolapse is not suspected, as it will delay transport and may worsen hemorrhage.
* Communication: Use closed-loop communication. Repeat back critical orders. Designate one nurse to document the timeline of events, interventions, and responses.
* Family Support: Briefly and calmly inform the support person of the emergency and that the team is taking the client for an emergency cesarean. Direct them to a waiting area and assign a staff member to provide updates.
Nursing Procedure & Medication FlowEmergency Cesarean Preparation Procedure:
1. Activate institutional OB emergency protocol (e.g., "Code White" or "OB STAT").
2. Discontinue any oxytocin infusion immediately.
3. Assist anesthesia team with rapid-sequence induction for intubation.
4. Perform a "time-out" in the OR, even in an emergency, to verify patient identity, procedure, and site.
5. Anticipate the need for blood products (Type O negative uncrossmatched blood may be used in extreme emergencies). Have massive transfusion protocol supplies ready.
6. Assign one nurse to be the "baby nurse" to receive and assess the neonate with the NICU team.Medication Anticipation:
* Uterotonics (e.g., Oxytocin, Methylergonovine, Carboprost): May be ordered postpartum to ensure uterine contraction after repair, but are ineffective for a ruptured uterus.
* Antibiotics: Broad-spectrum IV antibiotics will be administered prophylactically after cord clamping.
* Blood Products: Packed Red Blood Cells (PRBCs), Fresh Frozen Plasma (FFP), Platelets, and Cryoprecipitate may be needed for resuscitation and correction of coagulopathy.
A Word from Your Senior Nurse
"Uterine rupture is one of the most terrifying events in obstetrics. Your ability to recognize it instantly and act without hesitation will save two lives. In these moments, your brain might scream to start an IV or give oxygen first—and those are vital—but your hands need to be calling the team and moving the bed toward the OR. Think of it as the OB version of a 'Code Blue.' Your primary role is to initiate the system that delivers definitive care. In clinicals and on the NCLEX, always ask yourself: 'What is the problem that will kill this patient fastest, and what is the one action that will directly stop it?' For uterine rupture, the answer is always surgery."
Uterine Rupture — A full-thickness tear through the uterine wall and serosa, often during labor, leading to hemorrhage, fetal compromise, and maternal shock. A true obstetric emergency.
Fetal Bradycardia — A fetal heart rate (FHR) baseline below 110 beats per minute. Persistent bradycardia, especially with loss of variability, is an ominous sign of severe fetal hypoxia/acidosis.
Hypovolemic Shock — A state of circulatory collapse due to loss of intravascular volume (e.g., from hemorrhage). Signs include tachycardia, hypotension, tachypnea, cool/clammy skin, and altered mental status.
VBAC (Vaginal Birth After Cesarean) — An attempt to deliver vaginally by a woman who has had a previous cesarean birth. It carries a small but significant risk of uterine rupture, which requires careful monitoring during labor.
Tocometer — The component of the electronic fetal monitor that measures uterine activity (contractions) via a pressure-sensitive transducer placed on the maternal abdomen.