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?

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.

Clinical Priority Setting in Preeclampsia with DIC

When a client with severe preeclampsia develops disseminated intravascular coagulation (DIC), the clinical picture shifts from a hypertensive disorder of pregnancy to a life-threatening hemorrhagic and thrombotic emergency. The pathophysiologic cascade is critical to understand: severe preeclampsia causes widespread endothelial dysfunction, which triggers the uncontrolled activation of the coagulation system. Clotting factors and platelets are consumed, microthrombi form in small vessels, and simultaneously, the fibrinolytic system is activated, leading to a paradoxical state of simultaneous clotting and bleeding. This process can rapidly lead to end-organ damage and hemodynamic collapse.

The NCLEX-RN examination consistently prioritizes interventions using the "ABC" (Airway, Breathing, Circulation) framework, and this scenario is a classic application. While all the listed options are appropriate components of care, the highest priority is to first assess and stabilize the client's immediate physiologic stability. The foundation of DIC management is restoring and maintaining perfusion and oxygenation, not immediately addressing the inciting cause or replacing coagulation factors.

Analysis of Options

- Option 1: Administer fresh frozen plasma as ordered. Fresh frozen plasma (FFP) replaces clotting factors and is a key treatment for the consumptive coagulopathy of DIC. However, it is a pharmacologic intervention that addresses the underlying laboratory abnormality. Before administering any blood product, the nurse must first ensure the client has a patent airway, is breathing effectively, and has a functional circulatory system to transport the transfused factors. An intervention cannot be effective if the body's basic perfusion framework is failing.

- Option 2: Monitor for signs of bleeding and bruising. Ongoing assessment for overt and occult bleeding is a critical nursing responsibility in DIC. However, "monitoring" is a secondary, ongoing action. It is not the highest priority when a client is in an acute, unstable crisis where immediate life-sustaining measures are required. The priority is to act on the most immediate threat to life, which is assessed through the ABCs.

- Option 3: Prepare for emergency cesarean delivery. Delivery of the fetus and placenta is the definitive treatment for severe preeclampsia, as it removes the pathologic source of the endothelial dysfunction. However, performing surgery on a patient in the midst of an acute DIC crisis with active coagulopathy would be catastrophic, leading to uncontrolled surgical hemorrhage. The client must first be hemodynamically stabilized, and her coagulopathy must be addressed, before any operative intervention can be safely considered. The immediate threat is maternal death from shock, not the continuation of the pregnancy.

- Option 4: Assess airway, breathing, and circulation status. This is the correct and highest-priority action. The ABC assessment is the cornerstone of emergency nursing for any critically ill client. In the context of DIC, a compromised airway from altered consciousness, respiratory distress from pulmonary microthrombi or edema, and circulatory collapse from hemorrhage and third-spacing are all immediate, lethal threats. The nurse's initial, rapid assessment determines the sequence of all subsequent life-saving interventions, such as oxygen administration, intravenous fluid resuscitation, and vasopressor support, which must be established to preserve organ function before targeting the underlying coagulopathy ^[1].

The clinical priority for a client with a hypertensive disorder of pregnancy who develops a critical complication like DIC is to systematically evaluate and support the fundamental physiologic systems necessary for survival, starting with the airway, breathing, and circulation.