A 35-year-old gravida 4, para 3 client at 32 weeks gestation presents to the emergency department 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. Abruptio placentae is suspected. What is the priority nursing intervention?
The client appears anxious and states, "Something is terribly wrong with my baby." The physician has been notified and is en route to the unit.
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 operating room✓ 정답
해설
Immediate cesarean delivery is the priority due to fetal compromise (heart rate 90 bpm) and maternal hemorrhage (hypotension, tachycardia), which indicate life-threatening abruptio placentae. Other interventions are supportive but secondary to urgent delivery.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with suspected Abruptio placentae (Placental abruption) showing signs of maternal and fetal compromise. Abruptio placentae is the premature separation of the placenta from the uterine wall, which can lead to concealed or revealed hemorrhage, uterine irritability, and compromised fetal oxygenation. The scenario presents a Key Point!true obstetric emergency with classic signs: severe pain, rigid abdomen, vaginal bleeding, maternal hypotension (BP 90/60 mmHg), tachycardia (HR 120 bpm), and ominous fetal heart rate (FHR) findings (90 bpm with minimal variability).
Answer Rationale: The priority is Prepare for immediate cesarean delivery and notify the operating room. This is because the primary problem is a compromised placenta that can no longer sustain the fetus, coupled with ongoing maternal hemorrhage. The fetal bradycardia indicates severe hypoxia, and the maternal vital signs suggest hypovolemic shock. The definitive treatment to stop the hemorrhage and potentially save the fetus is rapid delivery. All other actions are supportive but must not delay the primary intervention of emergency delivery.
Distractor Analysis:
Option 1 (Administer oxygen): While oxygen administration is a supportive measure to increase maternal-fetal oxygenation, it does not address the root cause—the separated placenta. It is a secondary intervention.
Option 2 (IV access and fluids): Establishing IV access and starting fluid resuscitation is critical for managing maternal hypovolemia and shock. However, in this acute, life-threatening scenario with fetal distress, the nurse would initiate this while simultaneously preparing for surgery. It is a concurrent, not the singular priority, action.
Option 3 (Left lateral position): Positioning on the left side improves venous return and placental perfusion by taking pressure off the inferior vena cava. This is a correct and important intervention for fetal well-being, but again, it is a supportive measure that does not resolve the underlying catastrophic event.
Related Concepts: This scenario integrates knowledge of obstetric emergencies, fetal monitoring interpretation, and the nursing principle of prioritizing interventions that address the Key Point!life-threatening problem for both mother and fetus. The nurse's role is to recognize the emergency, initiate supportive care, and facilitate the definitive treatment without delay.
Pathophysiology: Separation causes hemorrhage into the decidua basalis, forming a hematoma that further separates the placenta. This destroys the area for gas/nutrient exchange.
Drugs: IV fluids (Lactated Ringer's, Normal Saline) for volume. Blood products may be needed. Tocolytics (like magnesium sulfate) are contraindicated in abruption.
Memory Tips
Abruption = "Rupture" + "Abdominal": Think of a sudden rupture causing severe abdominal pain and a rigid "board-like" abdomen.
High-Frequency NCLEX Topics
NCLEX loves testing prioritization in obstetric emergencies. You must distinguish between urgent (needs action now) and important (needs to be done soon) interventions. The rule: If both mother and baby are in immediate danger (like here), the action that saves both (emergency delivery) is always the top priority over supportive measures.
Watch Out for Question Variations!
Slight Variation: "The client is at 28 weeks with a small abruption, stable vitals, and a reassuring FHR strip." The priority may shift to monitoring, bed rest, and corticosteroid administration for fetal lung maturity, not immediate delivery.
Different Angle: The question might ask for the first action instead of the priority. "First" often implies an initial assessment or stabilizing action (e.g., apply oxygen, position, start IV), while "priority" implies the most critical action for the outcome (delivery).
Nursing Clinical Practice GuideClinical Scenario: You are the charge nurse in Labor & Delivery. A patient is rushed in from triage with the presentation described. The monitor shows fetal bradycardia. The patient is pale, diaphoretic, and clutching her abdomen.
Nursing Intervention Strategy:
Immediate Action (Simultaneous): Yell for help. While calling the physician and OR, you or another nurse should:
Apply a non-rebreather mask at 10-15 L/min (not a nasal cannula).
Position patient in left lateral tilt.
Start two 16- or 18-gauge IV lines and run isotonic fluids wide open.
Draw labs: CBC, coagulation panel (PT/PTT, fibrinogen), type and crossmatch for 4+ units of blood.
Rapid Preparation: The primary nurse focuses on OR prep: ensuring the consent is signed (if possible), notifying anesthesia, preparing the surgical suite, and arranging for neonatal resuscitation team (NICU) to be present.
Ongoing Monitoring & Support: Continuously monitor maternal BP, HR, O2 saturation, and FHR. Provide clear, calm explanations to the patient and partner. Document everything meticulously, including times of onset, notification of team, and interventions.
Patient Safety and Precautions:
Do NOT perform vaginal exams if placenta previa has not been ruled out by ultrasound. In a true emergency, this may be bypassed.
Monitor for DIC: Watch for bleeding from IV sites, gums, or oozing. Report abnormal lab values (low fibrinogen, elevated PT/PTT) immediately.
Transport Safety: Ensure the patient is transported to OR swiftly and safely, with monitoring continued en route.
Nursing Procedure & Medication FlowProcedure: Managing Massive Obstetric Hemorrhage
1. Activate massive transfusion protocol if available.
2. Administer warmed IV fluids and blood products as ordered.
3. Prepare uterotonic medications (like Oxytocin, Methylergonovine) for administration after delivery to promote uterine contraction and control bleeding.
4. Assist with possible interventions like Bakri balloon tamponade or surgical measures if needed.
A Word from Your Senior Nurse
"In moments like these, your ability to stay calm, think clearly, and act decisively saves lives. You are the coordinator of care. While your hands are starting the IV, your mind is already in the OR, and your voice is providing reassurance to a terrified mother. This integrated, multi-tasking mindset is the essence of high-acuity nursing. For the NCLEX, remember: when the fetus is in distress and the mother is unstable, the clock is ticking. The answer is almost always the one that gets the baby out safely and stops the bleeding—fast."