Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse in Labor & Delivery. A 32-year-old G2P1 at 32 weeks arrives via ambulance complaining of sudden, severe abdominal pain and feeling faint. She has a history of chronic hypertension. Her abdomen is rigid and tender to touch.
Nursing Intervention Strategy:- 1Immediate Assessment (First 2 minutes)Apply the EFM transducer to obtain a continuous FHR tracing. Simultaneously, have another nurse or assistant obtain maternal vital signs and establish two large-bore IV lines.
- 2Positioning & OxygenPlace the client in a left lateral tilt position to maximize placental perfusion. Administer oxygen via non-rebreather mask at 10-15 L/min to increase maternal-fetal oxygen saturation.
- 3Monitoring & DocumentationContinuously monitor FHR for signs of distress (bradycardia, late or variable decelerations, loss of variability). Quantify vaginal bleeding (pad count, weigh pads). Assess uterine tone frequently—it may become board-like.
- 4Communication & PreparationNotify the obstetrician and anesthesia team immediately. Prepare for emergency cesarean delivery: ensure the operating room is ready, obtain informed consent, and administer preoperative medications as ordered.
Patient Safety and Precautions:
• Do NOT perform a vaginal examination if placenta previa has not been ruled out by ultrasound. In abruption, an exam may not be contraindicated but should be done cautiously by the provider.
• Monitor for Disseminated Intravascular Coagulation (DIC): Abruption releases thromboplastin, which can trigger DIC. Monitor for signs of abnormal bleeding from IV sites, gums, or in urine.
• Fluid Resuscitation: Administer IV crystalloids (e.g., Lactated Ringer's) and blood products as ordered to treat maternal hypovolemic shock, but be mindful of fluid overload, especially if the client has hypertension.
Nursing Procedure & Medication Flow
Procedure: Initiating Continuous Electronic Fetal Monitoring (EFM)
1. Explain the procedure to the client.
2. Place the ultrasound transducer (for FHR) on the maternal abdomen where the FHR is loudest.
3. Place the tocodynamometer (for contractions) over the uterine fundus.
4. Ensure both signals are clear and the paper is running. Interpret the baseline FHR, variability, and presence of accelerations or decelerations.Medication: Corticosteroids (if time allows)
• Drug: Betamethasone 12 mg IM x 2 doses 24 hours apart.
• Purpose: To promote fetal lung maturity if delivery is anticipated between 24 and 34 weeks.
• NCLEX Point: This is a supportive measure but does not delay emergency delivery for fetal distress.
A Word from Your Senior Nurse
"In the chaos of an abruption, your calm, prioritized actions save two lives. Your first move is to 'find the baby' on the monitor. That strip of paper is your direct line to the fetus's well-being. While you're doing that, your team is addressing the mom. This is the essence of obstetric nursing: dual vigilance. On the NCLEX, they want to see that you know the fetus is the most vulnerable patient in the room. In clinicals, you'll feel the tension of a rigid abdomen and see the fear in a mother's eyes. Let your knowledge guide your hands—assess the FHR, tilt her left, give her oxygen. You've got this."