A pregnant client at 28 weeks gestation is admitted with severe preeclampsia and develops disseminated intravascular coagulation (DIC). Which nursing action should be the highest priority?
1Administer fresh frozen plasma as ordered
2Monitor for signs of bleeding and bruising
3Prepare for emergency cesarean delivery
4Assess airway, breathing, and circulation status✓ 정답
해설
In DIC, the priority is always ABCs (airway, breathing, circulation) as massive bleeding can rapidly compromise vital functions. Other actions are important but secondary to stabilizing life-threatening conditions.
Core Nursing ExplanationKey Concept Analysis: This question integrates two critical, life-threatening obstetric conditions: Severe Preeclampsia and Disseminated Intravascular Coagulation (DIC). The core theme is prioritization of nursing actions in a rapidly deteriorating patient. In DIC, the body's clotting system is overactivated, leading to widespread microthrombi that consume clotting factors and platelets, followed by severe, uncontrolled bleeding. This can lead to hypovolemic shock, organ ischemia, and death. The fundamental nursing principle is always to assess and support the ABCs (Airway, Breathing, Circulation) first, as these are immediately life-sustaining.
Answer Rationale: Key Point! The highest priority action is to Assess airway, breathing, and circulation status. This is the foundational step of the nursing process and emergency care. A patient with DIC can hemorrhage internally or externally, leading to airway compromise from decreased consciousness, ineffective breathing from hypovolemia or pulmonary complications, and circulatory collapse from massive blood loss. Stabilizing these vital functions is the immediate priority before addressing the underlying cause or administering specific treatments.
Distractor Analysis:
Watch out for confusion! While Administer fresh frozen plasma (Choice 1) is a correct treatment for DIC to replace clotting factors, it is a dependent nursing intervention that follows physician orders and is not the first action. The nurse must first ensure the patient is stable enough to receive the infusion.
Watch out for confusion!Monitoring for signs of bleeding (Choice 2) is a crucial ongoing assessment in DIC but is part of a more focused circulatory assessment. It is encompassed within the broader, primary "C" (Circulation) of the ABCs. The ABC assessment is more immediate and comprehensive.
Watch out for confusion!Preparing for emergency cesarean delivery (Choice 3) addresses the definitive treatment for severe preeclampsia (delivery of the placenta) and may be urgently needed. However, if the mother's ABCs are not supported first, she may not survive the surgery. The mother's physiological stability is the priority over fetal delivery in this acute maternal crisis.
Related Concepts: This scenario highlights the nursing process and Maslow's Hierarchy of Needs. Physiological needs (airway, breathing) must be met before safety needs (treating the disease). It also demonstrates the principle of "treat the cause, but stabilize the patient first." In obstetric emergencies, the nurse must rapidly assess both maternal and fetal status, but maternal stability is paramount.
Concept Summary
Concept
Key Points
DIC Pathophysiology
Uncontrolled activation of clotting cascade → microthrombi → consumption of platelets & clotting factors → simultaneous clotting and hemorrhage.
ABC Priority
Airway, Breathing, Circulation. The universal first step in any emergency or patient deterioration.
Severe Preeclampsia
Hypertension + proteinuria + end-organ dysfunction (CNS, hepatic, renal, hematologic). DIC is a catastrophic complication.
Nursing Prioritization
Always address life-threatening issues (ABCs) before disease-specific treatments or procedures.
Side-by-Side Comparison!
Priority Action (Correct)
Important but Secondary Actions (Distractors)
Reason for Priority
Assess ABCs
Administer FFP, Monitor for bleeding, Prepare for C-section
Ensures patient is physiologically stable to receive further treatment or undergo surgery. Without a patent airway and adequate perfusion, all other interventions fail.
Maternal Stabilization
Fetal Delivery
The best chance for fetal survival is a stable mother. Addressing the maternal crisis (hemorrhagic shock from DIC) directly benefits the fetus by restoring uteroplacental perfusion.
Pharmacology (FFP): Fresh Frozen Plasma contains all clotting factors. It is used to replace consumed factors in DIC. It is not a first-line emergency drug like oxygen or fluids for ABC support.
Obstetric Link: The placenta in severe preeclampsia is ischemic and dysfunctional. Abruption or release of placental debris can be the trigger for DIC.
Memory Tips
ABCs Always First: "Airway, Breathing, Circulation – Save the mom, then fix the situation."
DIC Mnemonic: "Death Is Coming" – highlights urgency. Or "Clotting Consumes, then Bleeding Begins."
Prioritization Rule: When in doubt on NCLEX, if an option involves assessing ABCs, vital signs, or level of consciousness in an unstable patient, it is often the correct priority.
High-Frequency NCLEX Topics
This integrates several high-yield NCLEX areas: Prioritization (ABCs), Obstetric Emergencies (Preeclampsia), and Hematologic Disorders (DIC). NCLEX loves to test if you know to stabilize the patient before treating the disease. Expect questions that pair a specific medical condition with a sudden change in status, forcing you to choose between a disease-focused action and a fundamental safety action.
Watch Out for Question Variations!
Symptom Identification: "Which finding in a client with severe preeclampsia is most indicative of developing DIC?" (Answer: Unexplained bleeding from IV sites, petechiae, ecchymosis).
Intervention Priority Shift: "After stabilizing the ABCs for a client with preeclampsia and DIC, which action should the nurse take next?" (Answer: Likely Prepare for emergency delivery, as delivery of the placenta removes the trigger).
Medication Focus: "The provider orders fresh frozen plasma for a client with DIC. Which assessment is most important before administration?" (Answer: Assess for fluid overload/CHF, as FFP is a volume expander).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the labor and delivery unit. A 28-year-old G1P0 at 28 weeks is admitted with BP 170/110, +3 proteinuria, and headache. She is started on magnesium sulfate. Two hours later, you note oozing from her IV insertion site, new petechiae on her chest, and she reports sudden, severe abdominal pain. Her heart rate is 130 bpm, and her blood pressure drops to 90/60.
Nursing Intervention Strategy:
Immediate Assessment (ABCs):
Airway: Call her name. Is she responsive? Is her airway patent?
Breathing: Assess rate, depth, oxygen saturation. Apply oxygen via non-rebreather mask at 10-15 L/min.
Activate & Communicate: Call a rapid response or code OB. State clearly: "I have a 28-week preeclamptic patient with suspected DIC, showing signs of bleeding and hemodynamic instability."
Simultaneous Actions: While supporting ABCs:
Establish two large-bore IV lines (18-gauge or larger) for rapid fluid and blood product administration.
Draw stat labs: CBC, coagulation panel (PT/PTT/INR, fibrinogen, D-dimer), type and crossmatch.
Place the patient in left lateral position if possible to optimize venous return and placental blood flow.
Continuously monitor fetal heart rate.
Prepare for Definitive Care: Once the team is present and ABCs are being managed, prepare for the likely emergency cesarean delivery: ensure the OR is ready, consent is obtained, and necessary medications (e.g., additional magnesium sulfate, antibiotics) are available.
Patient Safety and Precautions:
Magnesium Sulfate: Continue infusion for seizure prophylaxis but monitor closely for toxicity (loss of reflexes, respiratory depression) especially if renal function declines.
Blood Products: When administering FFP, cryoprecipitate, or platelets, use a blood warmer if possible, follow facility protocol for verification, and monitor for transfusion reactions (fever, chills, urticaria, dyspnea) and fluid overload.
Handling: Minimize invasive procedures (venipunctures, injections) due to bleeding risk. Apply prolonged pressure to any puncture sites.
Nursing Procedure & Medication FlowManaging a Patient with DIC:
Assessment: Frequent vital signs (q5-15min), strict I&O, neurological checks, assessment for occult bleeding (guaiac stool, urine dip for blood), skin assessment for petechiae/purpura.
FFP: Replaces clotting factors. Thawed, must be used within 24 hours.
Cryoprecipitate: Rich in fibrinogen and Factor VIII.
Platelets: Given if count is very low (<20,000/mm3) or if actively bleeding.
Packed Red Blood Cells (PRBCs): For significant blood loss to restore oxygen-carrying capacity.
A Word from Your Senior Nurse
"Nursing in high-risk OB is about being vigilant for the subtle signs that precede a catastrophe. That oozing IV site or new bruise in a preeclamptic patient isn't just 'something to note' – it's a red-alert siren for DIC. Your brain should immediately go to ABCs. In clinicals and on the NCLEX, they are testing your ability to not get distracted by the complex diagnosis and to remember the bedrock of nursing: first, ensure your patient can breathe and has a pulse. Everything else – the medications, the surgery, the monitoring – builds on that stable foundation. Think like a first responder first, and a specialist second."
Disseminated Intravascular Coagulation — A life-threatening condition characterized by widespread activation of the clotting cascade, leading to formation of microthrombi throughout the body, consumption of clotting factors and platelets, and ultimately severe bleeding.
Preeclampsia — A hypertensive disorder of pregnancy occurring after 20 weeks gestation, characterized by new-onset hypertension and proteinuria, with or without signs of end-organ damage (severe features).
ABCs (Airway, Breathing, Circulation) — The fundamental priority sequence in emergency care and patient assessment, focusing on establishing and maintaining a patent airway, effective breathing, and adequate circulation/perfusion.
Fresh Frozen Plasma — A blood product containing all coagulation factors, used to replace clotting factors in conditions like DIC, liver failure, or massive transfusion.
Magnesium Sulfate — A medication used in obstetrics for seizure prophylaxis in patients with preeclampsia/eclampsia and for fetal neuroprotection in preterm labor. It is a central nervous system depressant and requires careful monitoring for toxicity.