A pregnant client at 28 weeks gestation is admitted with pla… | 마이메르시 MyMerci
Maternal Newborn Health
문제

A pregnant client at 28 weeks gestation is admitted with placental abruption and develops disseminated intravascular coagulation (DIC). Which laboratory finding would be most indicative of DIC in this client?

해설
DIC involves consumption of clotting factors and fibrinolysis, leading to decreased fibrinogen and elevated FDPs. Other options do not reflect the characteristic lab abnormalities of DIC.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses your understanding of the characteristic laboratory findings in Disseminated Intravascular Coagulation (DIC), a life-threatening complication of conditions like placental abruption. DIC is a paradoxical state where widespread, inappropriate clotting (thrombosis) occurs throughout the microvasculature, consuming clotting factors and platelets. This is followed by a secondary, massive activation of the fibrinolytic system to break down the clots, leading to a simultaneous bleeding tendency. The lab findings reflect this "consumptive coagulopathy."

Answer Rationale: Key Point! In DIC, the rampant clotting consumes fibrinogen (a key clotting factor) and platelets, causing their levels to drop. Simultaneously, the breakdown of the numerous clots generates large amounts of Fibrin Degradation Products (FDPs), including D-dimer. Therefore, the classic triad of DIC lab findings includes: Decreased Fibrinogen, Decreased Platelets (Thrombocytopenia), and Elevated FDPs/D-dimer. Option ③ accurately describes two of these hallmark abnormalities.

Distractor Analysis:
Watch out for confusion! Option ①: Elevated fibrinogen levels is incorrect. Fibrinogen is an acute-phase reactant that often increases in pregnancy and inflammation, but in DIC, it is consumed faster than it can be produced, leading to low levels.
• Option ②: Normal PT (Prothrombin Time) is incorrect. PT measures the extrinsic pathway. In DIC, clotting factors are consumed, leading to a prolonged PT (and PTT). A normal PT would not be expected in full-blown DIC.
• Option ④: Increased platelet count is the opposite of what occurs. Thrombocytopenia is a cardinal sign of DIC due to platelet consumption. While PTT is prolonged, the increased platelet count makes this option invalid.

Related Concepts: Placental abruption is a major obstetric cause of DIC because the release of thromboplastin from the damaged placenta into the maternal circulation triggers the catastrophic clotting cascade. Nursing priorities include monitoring for signs of bleeding (oozing from IV sites, petechiae, ecchymosis) and hypovolemic shock, while administering blood products (like cryoprecipitate for fibrinogen) as ordered. Concept SummaryDIC Pathophysiology: Uncontrolled activation of clotting & fibrinolysis → Consumption of factors/platelets → Simultaneous clotting and bleeding.
Classic Lab Triad: ↓ Fibrinogen, ↓ Platelets, ↑ FDPs/D-dimer.
Coagulation Times: Prolonged PT (Prothrombin Time), PTT (Partial Thromboplastin Time).
Common Triggers in OB: Placental abruption, amniotic fluid embolism, septic abortion, preeclampsia/HELLP syndrome.

Side-by-Side Comparison!
ConditionKey Lab FindingsPathophysiology
Disseminated Intravascular Coagulation (DIC)↓ Fibrinogen, ↓ Platelets, ↑ FDPs/D-dimer, Prolonged PT/PTTConsumptive coagulopathy from widespread microclotting.
Liver FailureProlonged PT (due to lack of factor synthesis), Variable platelets, Normal FDPsInability to synthesize clotting factors.
Hemophilia AProlonged PTT only, Normal PT, Normal Platelets & FibrinogenDeficiency in specific factor (Factor VIII).

Anatomy, Physiology & Pharmacology PointsFibrinogen: Synthesized by the liver; converted to fibrin by thrombin to form a clot mesh.
FDPs/D-dimer: Products released when plasmin breaks down fibrin clots. Elevated levels indicate active clotting and fibrinolysis.
Pharmacology: Treatment for DIC is primarily supportive and targeted at the cause. Blood product replacement (fresh frozen plasma, cryoprecipitate, platelets) may be given to correct deficits, but this is done cautiously while treating the underlying trigger (e.g., delivering the baby in placental abruption).

Memory TipsAcronym for DIC Labs: "Fibrinogen is Falling, Platelets are Plummeting, FDPs are Flying high."
Think of a "Fire": DIC is like a fire (clotting) burning through all the firewood (clotting factors & platelets). The fire department (fibrinolytic system) comes and puts out the fire, leaving behind water and ash (FDPs).

High-Frequency NCLEX Topics DIC is a high-acuity, life-threatening condition frequently tested. The NCLEX expects you to:
1. Recognize the clinical triggers (sepsis, trauma, obstetric emergencies).
2. Identify the classic lab profile (as in this question).
3. Prioritize nursing assessments (vital signs, bleeding from all sites, neurological status for intracranial bleed).
4. Understand that treatment focuses on the underlying cause.

Watch Out for Question Variations! • Instead of asking for labs, a question might ask: "Which client finding is most concerning for developing DIC?" (Answer: Oozing of blood from venipuncture sites and gums).
• It might present a set of labs and ask you to prioritize which result to report immediately (e.g., critically low fibrinogen and platelets).
• It could combine DIC with a specific trigger like sepsis or amniotic fluid embolism and ask for the priority nursing intervention.

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on the labor and delivery unit. A 28-year-old G2P1 at 28 weeks is admitted with sudden, severe abdominal pain, a rigid "board-like" abdomen, and dark vaginal bleeding. Her blood pressure is 90/50, heart rate 128. The physician diagnoses placental abruption. Shortly after admission, you note petechiae on her chest and blood oozing from her IV insertion site.

Nursing Intervention Strategy:
1. Assessment & Monitoring: This is a OBSTETRIC EMERGENCY. Continuously monitor maternal vital signs and fetal heart rate. Assess for signs of DIC: check all mucous membranes, injection sites, and skin for petechiae/ecchymosis. Monitor urine output (indicator of renal perfusion and possible hemorrhage).
2. Immediate Actions: Establish two large-bore IV lines for rapid fluid and blood product administration. Administer oxygen via non-rebreather mask. Draw stat labs as ordered: CBC, coagulation panel (PT, PTT, fibrinogen, D-dimer), type and crossmatch.
3. Collaborative Care: Prepare for emergency cesarean delivery – the definitive treatment for abruption-induced DIC. Anticipate orders for blood product transfusion (packed red blood cells, fresh frozen plasma, cryoprecipitate specifically to replace fibrinogen, platelets).
4. Patient Safety & Precautions: Handle the patient gently to avoid causing bruising. Avoid unnecessary injections and IM medications. Apply pressure for extended time (5-10 minutes) after any venipuncture.

Nursing Procedure & Medication FlowBlood Product Administration: When administering cryoprecipitate (rich in fibrinogen), use a filtered IV administration set. Infuse as rapidly as tolerated to correct the deficit, often over 10-30 minutes per unit. Monitor closely for transfusion reactions.
Vital Sign Frequency: In active DIC, vital signs may be required as often as every 15 minutes. A rising heart rate and falling blood pressure can indicate ongoing concealed hemorrhage.

A Word from Your Senior Nurse "Placental abruption with DIC is one of the most terrifying scenarios in obstetrics. Your knowledge of those lab values isn't just for a test – it's a direct link to action. When you see that fibrinogen result come back at < 150 mg/dL (normal in late pregnancy is much higher, around 300-600 mg/dL), you know your patient is in critical danger of bleeding out. Your rapid recognition, communication with the team, and precise execution of orders can literally save two lives. In these moments, you are the linchpin of the emergency response. Study this patho deeply – it matters."

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