A pregnant client at 28 weeks gestation is diagnosed with severe preeclampsia and develops disseminated intravascular coagulation (DIC). Which nursing intervention should be the highest priority?
1Monitor for signs of bleeding and prepare for immediate delivery✓ 정답
2Administer heparin as prescribed to prevent further clot formation
3Encourage ambulation to prevent venous thromboembolism
4Increase fluid intake to maintain adequate hydration
해설
The priority is monitoring for bleeding and preparing for immediate delivery to remove the underlying cause of DIC (severe preeclampsia). Other options like heparin or ambulation are inappropriate in this context.
Core Nursing ExplanationKey Concept Analysis: This question integrates two critical, life-threatening obstetric complications: Severe preeclampsia and Disseminated Intravascular Coagulation (DIC). The core theme is determining the priority nursing intervention in this high-risk scenario. The pathophysiology involves placental ischemia from preeclampsia leading to widespread activation of the coagulation cascade, consuming clotting factors and platelets, which paradoxically results in both microvascular thrombosis and a high risk of hemorrhage. The definitive treatment for DIC in pregnancy is to Key Point! remove the underlying cause—the abnormal placenta.
Answer Rationale: The correct answer is Monitor for signs of bleeding and prepare for immediate delivery. This is the priority because:
1. Key Point! In obstetric DIC, the placenta is the source of the thromboplastin that triggers the coagulation cascade. Delivery is the definitive treatment to stop the pathological process.
2. The patient is at immediate risk for catastrophic hemorrhage (e.g., placental abruption, postpartum hemorrhage, intracranial hemorrhage) due to depleted clotting factors. Continuous monitoring for bleeding (e.g., petechiae, oozing from IV sites, vaginal bleeding, changes in mental status) is essential for early intervention.
3. This intervention aligns with the nursing process: Assessment (monitoring) and Implementation (preparing for a life-saving procedure).
Distractor Analysis: Watch out for confusion!Administer heparin (Option 2) is contraindicated in most cases of acute, consumptive DIC, especially in the setting of active bleeding or pre-delivery. Heparin is an anticoagulant that could worsen hemorrhage. It is sometimes used in chronic, low-grade DIC (e.g., with malignancy), but not in acute obstetric DIC. Watch out for confusion!Encourage ambulation (Option 3) is dangerous. A patient with severe preeclampsia is on strict bed rest to reduce blood pressure and increase placental perfusion. Furthermore, a patient with DIC and thrombocytopenia is at high risk for bleeding; a fall could be disastrous. Increase fluid intake (Option 4) is a supportive measure but not the priority. While hydration is important, fluid management in severe preeclampsia is complex due to the risk of pulmonary edema from capillary leak. Fluid intake would be carefully controlled, not simply increased.
Related Concepts: The management of DIC is always treat the cause. In pregnancy, that cause is the pregnancy itself (specifically the placenta). Nursing care focuses on vigilant assessment for complications of both the clotting (organ ischemia) and bleeding diatheses, while preparing for definitive treatment.
Concept Summary
Concept
Key Points
Severe Preeclampsia
Hypertension >160/110 mmHg with end-organ damage (headache, visual changes, epigastric pain, pulmonary edema, thrombocytopenia). Managed with magnesium sulfate for seizure prophylaxis and antihypertensives.
Disseminated Intravascular Coagulation (DIC)
A consumptive coagulopathy: widespread clotting depletes platelets and factors, leading to hemorrhage. Lab findings: low Platelets, high PT/PTT, low Fibrinogen, high D-dimer.
HELLP Syndrome
A severe variant of preeclampsia: Hemolysis, Elevated Liver enzymes, Low Platelets. Often associated with DIC.
Priority in Obstetric Emergencies
The priority is often to prepare for delivery (e.g., in placental abruption, uterine rupture, severe preeclampsia, fetal distress) to remove the source of the problem.
Side-by-Side Comparison!
Condition
Primary Problem
Key Nursing Priority
Severe Preeclampsia with DIC (This Case)
Placental pathology causing coagulopathy and hypertension.
Monitor for hemorrhage, prepare for immediate delivery.
Deep Vein Thrombosis (DVT) in Pregnancy
Hypercoagulable state causing a localized clot.
Administer anticoagulants (e.g., heparin), monitor for bleeding and Pulmonary Embolism (PE).
Postpartum Hemorrhage (PPH)
Uterine atony or trauma causing bleeding after delivery.
Massage fundus, administer uterotonics (Oxytocin), prepare for surgical intervention.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: The ischemic placenta releases tissue factor (thromboplastin) into the maternal circulation → activates extrinsic coagulation pathway → widespread microthrombi → consumption of platelets/fibrinogen → hemorrhage.
Drug Alert - Magnesium Sulfate: The first-line drug for preventing eclamptic seizures in preeclampsia. Nurses must monitor for toxicity: loss of deep tendon reflexes (first sign), respiratory depression, cardiac arrest. Have calcium gluconate (antidote) at bedside.
Drug Contraindication: Heparin and other anticoagulants are generally contraindicated in active, acute DIC with bleeding, as they can exacerbate hemorrhage.
Memory Tips
DIC Treatment Mnemonic: "Fix the Cause" (For DIC, Find and Fix the Cause). In pregnancy, the cause is the placenta.
Preeclampsia Triad: Remember "Hypertension, Proteinuria, Edema" (though edema is no longer required for diagnosis).
Priority Thinking: In any obstetric emergency, ask: "Is the baby out?" If not, and the mother is unstable, delivery is often the answer.
High-Frequency NCLEX Topics
This is a High Yield topic. The NCLEX-RN loves to test:
Priority setting in obstetric emergencies (using Maslow's Hierarchy or ABCs - Airway, Breathing, Circulation).
Complications of preeclampsia (eclampsia, HELLP, DIC, placental abruption).
Appropriate vs. contraindicated interventions (e.g., knowing when NOT to give heparin).
Nursing assessments for specific conditions (e.g., signs of bleeding in DIC, signs of magnesium toxicity).
Watch Out for Question Variations!
Shift from Symptom to Intervention: Instead of asking for the priority intervention, a question might ask: "The nurse assesses a client with severe preeclampsia and DIC. Which finding requires immediate action?" Correct answer would be a sign of active bleeding or neurological change.
Shift to Medication: "The provider orders magnesium sulfate for a client with severe preeclampsia. Which client assessment requires holding the medication and notifying the provider?" Correct answer: Respiratory rate of 10/min or Absent deep tendon reflexes.
Post-Delivery Focus: "Following delivery of a client with DIC, which intervention is most important?" The focus may shift to monitoring for postpartum hemorrhage and administering blood products (fresh frozen plasma, platelets, cryoprecipitate) as ordered.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the labor and delivery unit. A 28-year-old G2P1 at 28 weeks is admitted with a blood pressure of 170/110 mmHg, 4+ proteinuria, and a severe headache. She is started on a magnesium sulfate infusion. Suddenly, you notice petechiae on her chest and arms, and her IV site is oozing. Stat labs return showing platelets of 45,000/mm³ (normal: 150,000-400,000) and elevated PT/PTT. The diagnosis of severe preeclampsia with DIC is made.
Nursing Intervention Strategy:
Immediate Assessment (ABCs):
Airway/Breathing: Monitor respiratory status closely (MgSO₄ and risk of pulmonary edema).
Circulation: Frequent vital signs, including BP. Assess for signs of bleeding: check gums, skin (petechiae, ecchymosis), IV sites, vaginal bleeding. Monitor urine output (indicator of renal perfusion and bleeding). Perform a focused neurological assessment (headache, vision changes, confusion - signs of cerebral edema or hemorrhage).
Prepare for Delivery:
Notify the obstetrician and neonatal intensive care unit (NICU) immediately.
Prepare for a possible emergency cesarean section: ensure consent is signed, start a second large-bore IV line, ensure blood products are available and crossmatched.
Continue MgSO₄ infusion as ordered for seizure prophylaxis during the perioperative period.
Supportive Care & Monitoring:
Maintain strict bed rest with side rails up.
Administer blood products (fresh frozen plasma, platelets, cryoprecipitate) as ordered to replace clotting factors.
Manage environment: keep calm, quiet, and dimly lit to minimize seizure triggers.
Patient Safety and Precautions:
Contraindication: Do not administer heparin or encourage ambulation.
Medication Caution: Monitor for magnesium sulfate toxicity every hour: check deep tendon reflexes (patellar), respiratory rate (>12/min), and urine output (>30 mL/hr). Have calcium gluconate at the bedside.
Key Monitoring: Continuous fetal monitoring is essential until delivery. Monitor for signs of placental abruption (abdominal pain, uterine tenderness, dark vaginal bleeding).
Loading Dose: Often 4-6 grams IV over 20-30 minutes.
Maintenance Dose: 1-2 grams/hour via infusion pump.
Nursing Checks Q1H:
Deep Tendon Reflexes (DTRs): If absent, HOLD infusion and notify provider.
Respiratory Rate: If <12/min, HOLD infusion and notify provider.
Urine Output: If <30 mL/hr over 2 consecutive hours, notify provider (risk of magnesium accumulation).
Antidote: Calcium gluconate 1 gram IV push, readily available.
A Word from Your Senior Nurse
"Preeclampsia with DIC is one of the most terrifying scenarios in obstetrics. Your role as the nurse is to be the vigilant guardian. You are the one at the bedside who will see the petechiae first, notice the oozing IV site, or detect a change in the patient's mentation. In these critical moments, your knowledge that delivery is the cure directs all your actions. You're not just following orders; you're orchestrating the rapid preparation for a life-saving intervention while protecting the patient from harm. When you study, don't just memorize 'monitor for bleeding'—visualize the patient, see the signs, and feel the urgency of your preparation. That clinical mindset is what saves lives and what the NCLEX is truly testing."
Disseminated Intravascular Coagulation — A life-threatening condition characterized by widespread activation of the clotting cascade, leading to microvascular thrombosis and consumption of clotting factors/platelets, resulting in hemorrhage.
Severe Preeclampsia — A hypertensive disorder of pregnancy after 20 weeks with BP ≥160/110 mmHg and evidence of end-organ damage (proteinuria, thrombocytopenia, impaired liver function, pulmonary edema, cerebral/visual symptoms).
Magnesium Sulfate — The drug of choice for preventing and treating eclamptic seizures. It is a central nervous system depressant and smooth muscle relaxant. Requires close monitoring for toxicity (loss of DTRs, respiratory depression).
HELLP Syndrome — A severe complication of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets. Often progresses to DIC.
Placental Abruption — Premature separation of the placenta from the uterine wall. A potential cause or consequence of preeclampsia/DIC, presenting with painful vaginal bleeding, uterine tenderness, and fetal distress.