A pregnant client at 32 weeks gestation is admitted with severe preeclampsia and develops disseminated intravascular coagulation (DIC). Laboratory results show: platelets 45,000/mm³, fibrinogen 80 mg/dL, PT 18 seconds, PTT 65 seconds, and D-dimer elevated. Which nursing intervention should be the priority?
1Administer fresh frozen plasma as ordered
2Apply pressure to all bleeding sites
3Monitor for signs of intracranial hemorrhage✓ 정답
4Prepare for immediate cesarean delivery
해설
Monitoring for intracranial hemorrhage is the priority because it is the most life-threatening complication of DIC in pregnancy. Other interventions like administering FFP or applying pressure are supportive but secondary.
Core Nursing ExplanationKey Concept Analysis: This question integrates two critical, high-risk obstetric conditions: Severe Preeclampsia and Disseminated Intravascular Coagulation (DIC). The core theme is prioritizing nursing interventions based on the greatest threat to life. In DIC, the body's clotting system is overactivated, leading to widespread microthrombi that consume clotting factors and platelets, followed by a dangerous bleeding phase. In pregnancy, especially with preeclampsia, the risk of Key Point!intracranial hemorrhage (ICH) is significantly elevated due to severe hypertension and the coagulopathy of DIC. ICH is a leading cause of maternal mortality in these situations.
Answer Rationale: Key Point! The priority nursing intervention is Monitor for signs of intracranial hemorrhage. This is an assessment and surveillance action that aligns with the nursing process and patient safety. Early detection of neurological changes (like sudden severe headache, vision changes, altered mental status, seizures, or focal deficits) is critical for immediate intervention to prevent death or permanent disability. The lab values confirm severe DIC: low platelets (45,000/mm³), low fibrinogen (80 mg/dL), prolonged PT/PTT, and elevated D-dimer.
Distractor Analysis:
① Administer fresh frozen plasma (FFP): This is a correct and necessary medical order to replace clotting factors. However, it is an implementation action, not the immediate priority assessment. The nurse must first assess the patient's most critical status before administering treatments.
② Apply pressure to all bleeding sites: This is a supportive measure for external bleeding but does not address the imminent, invisible, and lethal threat of internal hemorrhage like ICH. It is a secondary intervention.
④ Prepare for immediate cesarean delivery: While Watch out for confusion! delivery of the fetus and placenta is the definitive treatment for DIC caused by placental abruption or severe preeclampsia/HELLP syndrome, "preparing" is an action that follows the decision to deliver. The nurse's first responsibility is to assess and stabilize the mother. Furthermore, the question does not specify an obstetric emergency like abruption; the immediate threat is the mother's neurological status.
Related Concepts: This scenario highlights the ABC (Airway, Breathing, Circulation) with a neurological priority adaptation in a specialized population. In a hemorrhagic crisis, Circulation is key, but in DIC with hypertension, the brain is the most vulnerable end-organ. Understanding the pathophysiology linking endothelial damage in preeclampsia to coagulopathy is essential.
Concept Summary
Concept
Key Points
Disseminated Intravascular Coagulation (DIC)
Systemic activation of coagulation → microthrombi → consumption of platelets & factors → hemorrhage. Lab: ↓Platelets, ↓Fibrinogen, ↑PT/PTT, ↑D-dimer.
Severe Preeclampsia
BP ≥160/110 mmHg, proteinuria, end-organ dysfunction (CNS, hepatic, renal, hematologic). Can progress to eclampsia (seizures) or HELLP syndrome.
Priority in DIC with Preeclampsia
1. Neurological assessment (for ICH). 2. Manage hypertension. 3. Replace blood products. 4. Prepare for delivery as indicated.
Prevents the #1 cause of maternal death in this scenario. Must be continuous.
Administer FFP
High Priority - Implementation (Treatment)
Replaces clotting factors to correct coagulopathy, but follows assessment.
Apply Pressure to Bleeding Sites
Supportive Intervention
Manages visible blood loss but does not address systemic or internal bleeding.
Prepare for Cesarean Delivery
Definitive Treatment Preparation
Removes the inciting cause (placenta) but is not the nurse's first independent action.
Anatomy, Physiology & Pharmacology PointsPathophysiology Chain: Severe Preeclampsia → Endothelial damage & vasospasm → Platelet activation/consumption & release of tissue factor → Triggers DIC cascade → Widespread thrombosis & coagulopathy → Risk of hemorrhage, especially in the brain due to uncontrolled hypertension.
Key Lab Values:
- Platelets: Normal >150,000/mm³. Critical risk of spontaneous bleed at <50,000/mm³.
- Fibrinogen: Normal in pregnancy is elevated (300-600 mg/dL). <150 mg/dL is concerning for DIC.
- D-dimer: Elevated indicates active fibrinolysis (breakdown of clots), a hallmark of DIC.
Memory TipsAcronym for DIC Priority in OB: "BRAIN First" Bleeding assessment (Neuro FIRST!)
Replace products (FFP, platelets, cryo)
Antihypertensives (Labetalol, Hydralazine)
Immediate delivery prep (Definitive Rx)
Notify team & document
High-Frequency NCLEX Topics
NCLEX loves to test prioritization in complex, multi-system failure scenarios like this. Remember: "Assess before you intervene." and "The greatest threat to life comes first." Neurological compromise (especially in preeclampsia) and airway problems are almost always top priority over medications or procedures.
Watch Out for Question Variations!
- If the question adds "client is having vaginal bleeding and severe abdominal pain", the priority might shift to suspecting placental abruption and preparing for emergency delivery.
- If the question asks for the "priority assessment" vs. "priority intervention", the answer is often the same: neurological monitoring.
- A question could ask which lab value is most critical to report: the critically low platelet count (<45,000) due to the high bleeding risk.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a Labor & Delivery unit. A 32-week pregnant patient, Ms. Jones, was admitted with BP 170/110 and 3+ proteinuria. She is on a magnesium sulfate infusion for seizure prophylaxis. Suddenly, you notice her gums are bleeding slightly, and she complains of a new, "worst headache of my life." Her labs return showing DIC.
Nursing Intervention Strategy:
1Immediate Assessment (Priority)Perform a focused neurological assessment. Use the Glasgow Coma Scale (GCS). Ask about headache characteristics, visual disturbances (scotomata), nausea. Check for facial asymmetry, hand grip strength equality, and any signs of seizure activity. Do not leave the patient alone.
2Safety & MonitoringEnsure the bed is in low position with side rails up. Maintain a quiet, dark environment to minimize stimulation. Continue strict intake and output monitoring. Monitor for magnesium toxicity (loss of DTRs, respiratory depression).
3Collaborative CareNotify the obstetrician and anesthesia team STAT. Anticipate orders for:
- Emergency antihypertensives (Labetalol IV or Hydralazine IV).
- Blood product transfusion (FFP, platelets, possibly cryoprecipitate for fibrinogen).
- Preparation for an emergency cesarean delivery.
4Patient/Family SupportProvide clear, calm explanations. The situation is frightening for the family; your professional demeanor is crucial.
Patient Safety and Precautions:- Avoid invasive procedures if possible (no IM injections, minimize IV sticks) due to bleeding risk.
- Handle the patient gently to prevent bruising.
- Monitor all sites for occult bleeding (IV sites, gums, urine, stool, injection sites).
- Watch out for confusion! Magnesium sulfate is for seizure prevention, NOT for treating hypertension. You must still administer antihypertensives as ordered.
Nursing Procedure & Medication FlowBlood Product Administration in DIC:
1Fresh Frozen Plasma (FFP)Thawed, must be administered within 24 hours. Use a blood filter. Infuse as ordered, typically over 30-60 minutes per unit. Monitor for transfusion reactions (fever, chills, urticaria, dyspnea).
2PlateletsInfuse rapidly, usually over 15-30 minutes per unit. Do not refrigerate; agitate the bag gently.
3Critical CalculationAlways verify the patient's identity with another nurse using two unique identifiers (name, date of birth) BEFORE initiating any blood product.
A Word from Your Senior Nurse
"In high-stakes situations like severe preeclampsia with DIC, your brain is your best tool. Panic helps no one. Your first job is to be the expert observer—your assessment findings drive the entire team's response. That sudden headache change? That's not just a complaint; it's a potential red flag for a catastrophic brain bleed. By prioritizing neurological monitoring, you are literally standing guard at the door to prevent maternal mortality. On the NCLEX and in real life, this principle holds: find the most immediate threat to life, and address it first. You've got this!"