A 28-year-old woman presents to the emergency department with severe right lower abdominal pain, vaginal spotting, and dizziness. Her last menstrual period was 7 weeks ago. Vital signs: BP 90/60 mmHg, HR 110 bpm, temperature 98.6°F. Transvaginal ultrasound reveals no intrauterine gestational sac, and beta-hCG level is 2,500 mIU/mL. The nurse suspects ectopic pregnancy. What is the priority nursing intervention?
2Establish large-bore IV access and prepare for emergency surgery✓ 정답
3Position the patient in Trendelenburg position
4Obtain a complete obstetric history and family planning preferences
해설
Priority is establishing large-bore IV access and preparing for emergency surgery due to hemodynamic instability from suspected ruptured ectopic pregnancy. Other interventions like methotrexate or history-taking are secondary when shock signs are present.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's ability to prioritize care for a patient with a suspected ectopic pregnancy showing signs of hypovolemic shock. An ectopic pregnancy is the implantation of a fertilized ovum outside the uterine cavity, most commonly in the fallopian tube. As the pregnancy grows, it can cause the tube to rupture, leading to severe internal hemorrhage. The patient's presentation—severe unilateral pain, vaginal spotting, dizziness, tachycardia (HR 110 bpm), and hypotension (BP 90/60 mmHg)—are classic signs of a ruptured ectopic pregnancy and impending shock. The diagnostic clues (absent intrauterine sac on ultrasound with a beta-hCG of 2,500 mIU/mL) confirm the high suspicion.
Answer Rationale: Key Point! In any emergency situation, the nursing priority follows the ABCs (Airway, Breathing, Circulation) and management of life-threatening conditions. This patient's vital signs indicate compromised circulation (hypotension and tachycardia) due to internal bleeding. Therefore, the immediate priority is to restore and support circulation. This is achieved by establishing large-bore IV access (e.g., two 18-gauge IV lines) for rapid fluid resuscitation and blood product administration, and preparing for emergency surgery (typically a salpingectomy) to stop the bleeding. This intervention directly addresses the threat to the patient's life.
Distractor Analysis:
• Watch out for confusion!Option 1 (Administer methotrexate): Methotrexate is a medical management option for a stable, unruptured ectopic pregnancy where the patient is hemodynamically stable. This patient shows clear signs of rupture and shock, making medical management contraindicated and surgery the urgent necessity.
• Option 3 (Trendelenburg position): The Trendelenburg position (head down, feet up) is no longer recommended as a standard intervention for shock. It can impair respiratory function and does not reliably improve cardiac output. The priority is IV access and fluid resuscitation.
• Option 4 (Obtain history): While a thorough history is an important part of comprehensive nursing care, it is not the priority when a patient is exhibiting signs of hemodynamic instability. Life-saving interventions come first. History can be obtained concurrently or after stabilization.
Related Concepts: The management of ectopic pregnancy depends entirely on the patient's stability. For a stable patient (normal vital signs, no signs of rupture), options include medical management with methotrexate or elective surgery. For an unstable patient (like this case), it is a surgical emergency. The nurse's role involves rapid assessment, initiating emergency protocols, providing emotional support, and preparing for possible blood transfusion.
Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in the ED. A young woman is brought in by her partner, clutching her lower abdomen, pale, and anxious. She reports sudden, sharp right-sided pain that started an hour ago.
Nursing Intervention Strategy:
1Immediate Assessment (ABCs)Quickly assess airway and breathing. Check vital signs, noting hypotension and tachycardia. Ask key questions: "Where is the pain? When was your last period? Are you dizzy or lightheaded?"
2Priority ActionCall for help and immediately establish two large-bore IV lines (16- or 18-gauge). Begin infusing isotonic crystalloid solution (e.g., Normal Saline or Lactated Ringer's) wide open to support blood pressure.
3Preparation for SurgeryNotify the OB/GYN surgeon and OR team. Draw stat labs (CBC, type and crossmatch for 2-4 units of blood). Insert a Foley catheter to monitor urine output (a key indicator of perfusion). Administer supplemental oxygen.
4Ongoing Monitoring & SupportContinuously monitor vital signs, oxygen saturation, and level of consciousness. Keep the patient NPO (nothing by mouth). Provide clear, calm explanations to the patient and her family. Offer emotional support, as this is a traumatic event involving potential loss of pregnancy and surgery.
Patient Safety and Precautions:
• Do not leave the unstable patient alone.
• Avoid administering analgesics that could mask symptoms or depress respirations until the patient is fully assessed and a plan is in place.
• Handle the patient gently; movement can exacerbate pain or bleeding.
• Key Point! In suspected ruptured ectopic pregnancy, time is tissue (and blood). Delays in establishing IV access or recognizing deterioration can be fatal.
Nursing Procedure & Medication FlowEmergency IV Access & Fluid Resuscitation:
• Goal: Restore intravascular volume.
• Procedure: Use large-bore catheters in large veins (e.g., antecubital). If peripheral access is difficult, consider an intraosseous (IO) line. Initiate a 1-2 liter fluid bolus as ordered and reassess.
• Medication/Blood: Have O-negative or type-specific blood available. Administer blood products per protocol if hemoglobin drops significantly (< 7 g/dL in an actively bleeding patient) or the patient remains unstable despite crystalloids.
A Word from Your Senior Nurse
"Ectopic pregnancy is one of those 'don't-miss' diagnoses in the ED. That combination of abdominal pain, vaginal bleeding, and a positive pregnancy test should always ring alarm bells. Your first job isn't to get the full social history; it's to make sure she has a working IV and a clear path to the operating room. In clinical practice, you'll see the fear in their eyes—they know something is terribly wrong. Your calm, efficient actions in those first minutes are what build trust and save lives. For the NCLEX, they love to test your ability to sort 'urgent' from 'important.' Here, urgent wins every time."
Ectopic Pregnancy — Implantation of a fertilized ovum outside the uterine endometrium, most commonly in the fallopian tube (tubal pregnancy). A life-threatening cause of first-trimester bleeding.
Beta-hCG (Human Chorionic Gonadotropin) — A hormone produced by the placenta. Levels double approximately every 48 hours in a normal early intrauterine pregnancy. A level above the "discriminatory zone" (often 1,500-2,000 mIU/mL) without a visible intrauterine sac on ultrasound is highly suggestive of an ectopic pregnancy.
Hypovolemic Shock — A state of inadequate tissue perfusion caused by loss of intravascular volume (e.g., from hemorrhage). Signs include tachycardia, hypotension, cool/clammy skin, decreased urine output, and altered mental status.
Salpingectomy — Surgical removal of a fallopian tube. This is the definitive treatment for a ruptured ectopic pregnancy to control hemorrhage.
Methotrexate — A folic acid antagonist chemotherapeutic agent used for medical management of a small, unruptured ectopic pregnancy in a hemodynamically stable patient. It stops the growth of the pregnancy tissue.