A 32-year-old gravida 2, para 1 client at 34 weeks gestation presents to the labor and delivery unit with sudden onset of severe abdominal pain and vaginal bleeding. Vital signs reveal blood pressure 90/60 mmHg, pulse 120 bpm, and respirations 24/min. The fetal heart rate shows late decelerations with decreased variability. What is the nurse's highest priority action?
1Prepare the client for immediate cesarean delivery
2Insert two large-bore IV catheters and begin fluid resuscitation
3Administer oxygen via face mask at 10 L/min
4Notify the physician immediately and prepare for emergency delivery✓ 정답
해설
This scenario suggests placental abruption, a life-threatening obstetric emergency requiring immediate physician notification and preparation for emergency delivery. Other actions (IV access, oxygen, cesarean preparation) are important but secondary to notifying the physician for urgent decision-making.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to prioritize actions in a suspected Placental abruption (Abruptio placentae). Abruption is the premature separation of the placenta from the uterine wall, causing maternal hemorrhage, fetal distress, and potential maternal coagulopathy. The patient's presentation—sudden severe pain, vaginal bleeding, hypotension, tachycardia, and fetal heart rate (FHR) abnormalities (late decelerations, decreased variability)—is classic for a severe abruption. The core nursing priority is to initiate the emergency response system to save both mother and fetus.
Answer Rationale: Key Point! In any obstetric emergency, the nurse's first action is often to activate the emergency response system. Here, that means immediately notifying the physician (or the obstetric rapid response team) while simultaneously preparing for the definitive treatment, which is emergency delivery. Option ④ combines these two critical, immediate steps: notification and preparation. The physician must be informed to make the definitive decision (e.g., stat cesarean vs. rapid vaginal delivery), and the nurse must have everything ready. This action initiates the coordinated team response required for this time-critical situation.
Distractor Analysis:
Option ① (Prepare for immediate cesarean delivery): While emergency cesarean is the likely outcome, the nurse cannot unilaterally decide this. Preparation should happen concurrently with or immediately after physician notification. Doing this first delays activating the essential decision-maker.
Option ② (Insert IVs and begin fluid resuscitation): Establishing IV access and starting fluid resuscitation for hypovolemic shock is a critical simultaneous action, but it is not the highest priority. In NCLEX logic, activating the system to get the patient to definitive treatment (delivery) takes precedence over initiating supportive measures, though in practice, a skilled nurse would delegate this task while calling the physician.
Option ③ (Administer oxygen): Administering high-flow oxygen to improve fetal and maternal oxygenation is important and should be done quickly. However, like IV fluids, it is a supportive measure that does not address the root cause (the separated placenta). It is a secondary intervention.
Related Concepts: This scenario tests the ABC (Airway, Breathing, Circulation) priority framework with an obstetric twist. In pregnancy, the patient is "two patients." When the fetus is in immediate jeopardy (as shown by late decelerations and decreased variability), interventions to relieve the cause of fetal compromise (i.e., delivery) become the ultimate priority, which requires immediate physician collaboration.
Late decelerations indicate uteroplacental insufficiency. Decreased variability suggests fetal acidemia/neurologic depression. Together, they signal urgent fetal compromise.
Nursing Priorities in OB Emergencies
1. Call for help (MD, team). 2. Support maternal physiology (O2, IV, monitor). 3. Prepare for definitive treatment (delivery).
Maternal Shock in Pregnancy
Supine hypotension can worsen shock. Position in left lateral tilt to displace the uterus off the inferior vena cava and improve venous return.
Side-by-Side Comparison!
Placental Abruption
Placenta Previa
Patho: Separation of normally implanted placenta.
Patho: Placenta implants over/very near cervical os.
Bleeding: Often concealed or dark red. Painful.
Bleeding: Bright red, painless.
Uterus: Firm, tender, hypertonic ("woody").
Uterus: Soft, non-tender.
FHR: Often abnormal (distress).
FHR: Usually normal initially.
Key Nursing Action: Prepare for emergency delivery.
Key Nursing Action: No vaginal exams! Bed rest, monitor.
Anatomy, Physiology & Pharmacology Points
Physiology: Abruption disrupts the maternal-fetal gas/nutrient exchange. Maternal hemorrhage reduces perfusion, causing fetal hypoxia (late decels). The release of thromboplastin can trigger Disseminated Intravascular Coagulation (DIC).
Pharmacology: In preparation for delivery/c-section, medications like Oxytocin (Pitocin) (to contract uterus post-delivery) or Magnesium sulfate (for neuroprotection in preterm delivery) may be needed. The nurse must be ready to administer these per protocol.
Previa = PAINLESS:Painless, Avoid exams, Instruction for bed rest, No labor, Low-lying placenta, Emergency c-section possible, Soft uterus.
High-Frequency NCLEX Topics
Placental abruption is a classic NCLEX emergency. The exam tests: 1) Recognizing the signs vs. placenta previa, 2) Understanding that painful bleeding + fetal distress = abruption, and 3) Applying priority-setting principles: Activate the team first when a life-threatening complication requiring a physician's order is identified.
Watch Out for Question Variations!
Shift from "Action" to "Assessment": "The nurse assesses the client and notes a rigid, board-like abdomen. This finding is most consistent with which condition?" (Answer: Abruption).
Shift to "Post-Delivery Care": "Following delivery for a client with abruption, the nurse should monitor for which complication?" (Answer: Hemorrhage or DIC).
Shift to "Teaching": "A client at 32 weeks with hypertension asks about warning signs. Which statement by the client indicates understanding of abruption?" (Answer: "I should call if I have sudden, severe stomach pain.").
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in triage. Ms. Lopez, 32, G2P1 at 34 weeks, is brought in by her partner. She is clutching her abdomen, crying in pain. She states, "The pain came out of nowhere, and then I started bleeding." Her skin is pale and clammy.
Nursing Intervention Strategy:
Immediate Action (Seconds 0-30): While helping her onto a stretcher, shout for help or use the call bell to alert the charge nurse and unit secretary to "STAT page OB to L&D triage, possible abruption." Simultaneously, apply the fetal monitor and manual BP cuff.
Simultaneous Assessment & Support (Seconds 30-90):
Airway/Breathing: Apply non-rebreather mask at 10-15 L/min. Position in left lateral tilt.
Circulation: While another nurse or tech obtains vital signs, you or a colleague insert two large-bore (16- or 18-gauge) IV catheters. Begin a bolus of isotonic crystalloid (e.g., Lactated Ringer's) wide open.
Monitor: Continuously assess FHR pattern, maternal vital signs, pain level, and amount of bleeding.
Communication & Preparation (Seconds 90+): The physician arrives. You provide a concise report: "Ms. Lopez, 34 weeks, sudden onset severe abdominal pain and moderate vaginal bleeding starting 20 minutes ago. BP 90/60, HR 120, FHR showing late decels with minimal variability. Uterus is rigid. Two IVs are in place with LR infusing. She's on 15L O2." You then prepare the OR for stat cesarean: ensure the crash cart is nearby, draw baseline labs (CBC, type and cross for 4 units, coagulation panel), and have oxytocin and emergency medications ready.
Patient Safety and Precautions:
NO VAGINAL EXAMS: In any third-trimester bleeding, a vaginal exam is contraindicated until placenta previa is ruled out by ultrasound. In abruption, it can worsen bleeding.
Monitor for DIC: Watch for oozing from IV sites, gums, or development of petechiae. Report abnormal lab values (e.g., increased PT/PTT, decreased fibrinogen, increased D-dimer) immediately.
Family Support: Provide clear, calm explanations to the patient and partner. The situation is terrifying for them.
Ensure informed consent is obtained by the physician.
Administer preoperative medications as ordered (e.g., antacid like Bicitra).
Perform a surgical "time-out" with the entire team.
Anticipate need for Oxytocin (Pitocin) infusion post-delivery to promote uterine contraction and control bleeding. Standard mix: 20-40 units in 1L LR, titrated to uterine tone.
Prepare for possible neonatal resuscitation: Call NICU team, have warmer and resuscitation equipment ready.
A Word from Your Senior Nurse
"In the chaos of an obstetric emergency, your brain will want to jump to ten tasks at once. Train your muscle memory: See disaster → Call for help → Support the patient → Prepare for the fix. That initial call gathers the cavalry. In this scenario, you are the quarterback calling the play. By notifying the physician immediately while prepping for delivery, you ensure the patient gets from 'critical' to 'in the OR' in the shortest time possible. On the NCLEX and in real life, that systems-thinking approach saves lives."
Placental Abruption (Abruptio Placentae) — The premature separation of a normally implanted placenta from the uterine wall before delivery of the fetus. It is a medical emergency causing maternal hemorrhage and fetal compromise.
Late Decelerations — A pattern on the fetal heart rate monitor where the deceleration begins at the peak of a contraction and recovers after the contraction ends. It indicates uteroplacental insufficiency and fetal hypoxia.
Left Lateral Tilt Position — Positioning a pregnant patient on her left side or tilting the pelvis to the left. This displaces the uterus off the inferior vena cava and aorta, improving venous return and cardiac output, which is critical in maternal hypotension or shock.
Disseminated Intravascular Coagulation — A life-threatening coagulopathy where widespread clotting consumes clotting factors and platelets, leading to simultaneous bleeding and thrombosis. A severe complication of placental abruption.
Oxytocin — A uterotonic medication used to induce or augment labor and to promote uterine contraction after delivery to control postpartum hemorrhage.