A 35-year-old woman at 37 weeks gestation is in active labor when she suddenly develops severe dyspnea, cyanosis, and hypotension. The fetal heart rate shows bradycardia. The nurse suspects anaphylactoid syndrome of pregnancy (ASP). What is the priority nursing action?
The patient becomes unresponsive with signs of cardiovascular collapse and respiratory distress during labor.
1Administer oxygen via nasal cannula at 2 L/min
2Position the patient in Trendelenburg position
3Call for immediate emergency assistance and prepare for cardiopulmonary resuscitation✓ 정답
4Increase the IV fluid rate to improve blood pressure
해설
ASP requires immediate emergency assistance and CPR preparation due to rapid cardiovascular collapse. Other options delay critical resuscitation.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to recognize and prioritize care for a life-threatening obstetric emergency: Anaphylactoid Syndrome of Pregnancy (ASP), also known as Amniotic Fluid Embolism (AFE). The pathophysiology involves amniotic fluid or fetal material entering the maternal circulation, triggering a catastrophic anaphylactoid (allergic-like) reaction and coagulopathy (DIC). This leads to rapid cardiovascular collapse, respiratory failure, and altered mental status, as seen in the scenario with dyspnea, cyanosis, hypotension, and unresponsiveness. Fetal bradycardia is a direct consequence of severe maternal hypoxia and shock.
Answer Rationale: Key Point! The priority action in any situation where a patient becomes unresponsive with signs of cardiovascular and respiratory collapse is to activate the emergency response system and initiate basic life support. Option ③, "Call for immediate emergency assistance and prepare for cardiopulmonary resuscitation (CPR)," is correct because ASP is a true medical emergency requiring a full code team for advanced cardiac life support (ACLS), rapid interventions, and likely emergency cesarean delivery to save both mother and fetus. The nurse alone cannot manage this crisis.
Distractor Analysis:
Watch out for confusion! Option ①: Administering low-flow oxygen via nasal cannula is grossly inadequate for a patient in severe respiratory distress and cardiovascular collapse. The priority is high-flow oxygen via a non-rebreather mask or bag-valve-mask ventilation as part of CPR, but only after calling for help.
Option ②: Placing the patient in Trendelenburg position (head down) is contraindicated in a patient with respiratory distress as it can further compromise lung expansion and is not a primary intervention for cardiovascular collapse from ASP.
Option ④: While aggressive fluid resuscitation is often part of the management protocol for ASP to support blood pressure, it is not the first action when the patient is unresponsive. The nurse must first ensure the patient has a pulse and is breathing or begin CPR. Rapid IV fluids may be administered by the emergency team once they arrive.
Related Concepts: The management of ASP follows the ABC (Airway, Breathing, Circulation) priority framework within the context of a team response. The ultimate treatment is supportive: oxygen, vasopressors, blood products for DIC, and expedited delivery of the fetus. Maternal and fetal survival depend on the speed of recognition and intervention.
Concept Summary
1. Sudden cardiovascular collapse (hypotension). 2. Respiratory distress (dyspnea, cyanosis). 3. Coagulopathy (DIC). Altered mental status and fetal distress are common.
Nursing Priority
Immediate activation of emergency response (code team), followed by ABCs: Airway, Breathing, Circulation. Prepare for CPR and emergency delivery.
Pathophysiology
Mechanical obstruction and immune-mediated reaction in pulmonary vasculature -> right heart failure, hypoxia, left heart failure, DIC.
Side-by-Side Comparison!
Obstetric Emergency
Key Features
Initial Nursing Action
Anaphylactoid Syndrome (ASP)
Sudden dyspnea, cyanosis, hypotension, coagulopathy during labor/delivery.
Call emergency/Code team. Prepare for CPR & emergency delivery.
Placental Abruption
Sudden, severe abdominal pain; dark vaginal bleeding; rigid, tender uterus; fetal distress.
Notify provider. Position left lateral. Administer O2. Start large-bore IV. Prepare for emergency delivery.
Uterine Rupture
Sudden, tearing abdominal pain; loss of uterine contraction; recession of fetal presenting part; maternal shock.
Notify provider immediately. Administer O2. Start large-bore IVs. Prepare for emergency laparotomy.
Eclampsia
Seizure in a patient with preeclampsia (hypertension, proteinuria).
Call for help. Maintain airway (position on side). Administer O2. Administer MgSO4 as ordered. Prepare for delivery.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Amniotic fluid (containing fetal squamous cells, lanugo, meconium) enters maternal venous sinuses in the uterus -> travels to pulmonary circulation -> triggers massive inflammatory/coagulation cascade -> pulmonary hypertension, right heart failure, severe hypoxia -> left heart failure, cardiovascular collapse -> Disseminated Intravascular Coagulation (DIC).
Fetal Physiology: Fetal bradycardia results from severe maternal hypoxia and decreased uteroplacental perfusion.
Pharmacology: Treatment is supportive. Key drugs may include: Vasopressors (e.g., epinephrine, norepinephrine) for hypotension, Blood products (FFP, platelets, cryoprecipitate) for DIC, and Oxygen as a drug.
Memory Tips
Acronym for ASP Symptoms:Sudden Dyspnea, Cyanosis, Collapse (SDCC).
Priority Reminder: "When mom crashes and baby's heart rate drops, STOP and CALL the code team." Your first action is never a solo intervention in a full arrest/impending arrest scenario.
Link to DIC: Think of ASP as a classic cause of obstetric DIC. Bleeding from IV sites, gums, or incisions is a late sign.
High-Frequency NCLEX Topics
NCLEX frequently tests prioritization in obstetric emergencies. ASP is a high-acuity topic. Remember: For any patient who becomes unresponsive or has absent pulses, the first step is always to activate the emergency response system/get help (or have someone else do it) before starting CPR or other interventions, according to current BLS (Basic Life Support) guidelines.
Watch Out for Question Variations!
Symptom Identification: "A laboring patient develops acute dyspnea and hypotension. Which condition should the nurse suspect?" (Answer: ASP/Amniotic Fluid Embolism).
Priority Intervention: "After calling the emergency team for a patient with suspected ASP, what is the nurse's next priority action?" (Answer: Initiate CPR if pulseless, or administer high-flow oxygen and position supine with left uterine displacement if patient has a pulse).
Monitoring for Complications: "The nurse is caring for a patient recovering from ASP. Which laboratory finding is most critical to monitor?" (Answer: Coagulation studies for DIC - PT, PTT, fibrinogen, platelets).
Nursing Clinical Practice GuideClinical Scenario: You are the labor nurse for Maria, G1P0 at 39 weeks. Her labor has been progressing normally. Suddenly, she cries out, "I can't breathe!" and clutches her chest. You note she is cyanotic around her lips, her blood pressure drops to 70/40, and she becomes less responsive. The fetal heart monitor shows a deep, prolonged deceleration to 80 bpm.
Nursing Intervention Strategy:
Immediate Action (Seconds 0-10): Shout for help! Activate the hospital's emergency obstetric code (e.g., "Code Blue" or "Maternal Rapid Response").
Assessment & Initial Care (Seconds 10-30):
Check for responsiveness and pulse. If absent, begin high-quality CPR with chest compressions.
If responsive with a pulse, immediately apply a non-rebreather mask at 15 L/min for oxygen.
Position supine with left lateral uterine displacement (manually displace the uterus to the left to prevent aortocaval compression and improve venous return). Do not use Trendelenburg.
Team-Based Management (Minutes 1-5):
Team arrives. Assist with endotracheal intubation if needed.
Establish two large-bore IV lines (14-16 gauge) for rapid fluid and blood product administration.
Prepare for emergency cesarean delivery at the bedside if maternal cardiac arrest occurs or fetal status is non-reassuring. The goal is delivery within 5 minutes of maternal arrest.
Administer medications and blood products as ordered by the team (vasopressors, tranexamic acid, blood components).
Ongoing Care & Monitoring: Continuously monitor vital signs, oxygen saturation, ECG, and fetal heart rate. Document everything meticulously, including times of symptom onset, interventions, and team responses.
Patient Safety and Precautions:
Never delay calling for help to start an intervention. In a code situation, extra hands are the most critical resource.
Avoid Trendelenburg position in patients with respiratory distress.
During CPR on a pregnant patient >20 weeks gestation, manual left uterine displacement is mandatory to ensure effective compressions.
Be aware that massive hemorrhage from DIC can occur. Monitor for bleeding from all sites.
Nursing Procedure & Medication FlowEmergency Response for Unresponsive Patient (BLS/ACLS in Pregnancy):
1. Verify unresponsiveness and shout for help/activate emergency system.
2. Check pulse (carotid) for no more than 10 seconds.
3. If no pulse: Begin CPR. Compression-to-ventilation ratio: 30:2. Use a backboard. Perform manual left uterine displacement.
4. When AED/defibrillator arrives: Use standard pads and energy doses. It is safe and indicated.
5. Medications in Code: Standard ACLS drugs (epinephrine 1 mg IV/IO every 3-5 minutes) are used. The team will consider perimortem cesarean delivery.
Medication Administration in ASP (Supportive Care):
Oxygen: Drug of choice for hypoxia. Administer via non-rebreather mask or via bag-valve-mask during CPR.
IV Fluids: Crystalloids (Normal Saline or Lactated Ringer's) for volume expansion. Use pressure bags for rapid infusion.
Vasopressors:Epinephrine is first-line for anaphylactoid shock and during cardiac arrest. Norepinephrine is often used for persistent hypotension post-ROSC (Return of Spontaneous Circulation).
Blood Products: Given for DIC. Monitor for transfusion reactions. Common orders: Packed Red Blood Cells (PRBCs), Fresh Frozen Plasma (FFP), Platelets, Cryoprecipitate (for fibrinogen).
A Word from Your Senior Nurse
"Anaphylactoid syndrome is one of the most terrifying emergencies in obstetrics because it strikes without warning in an otherwise normal labor. Your knowledge and swift action in those first seconds are what can change the outcome. In clinical practice, trust your gut. If a patient suddenly looks 'wrong' – pale, panicked, short of breath – don't wait for a full set of vitals to act. Call for help immediately. When studying, drill these high-acuity scenarios. Ask yourself: 'What is the very first thing I do?' Remember, in a true crisis, you are the coordinator of care until the team arrives. Staying calm, knowing your protocols, and being the patient's advocate is the essence of nursing in these moments. This mindset saves lives on the NCLEX and on the unit."