A 28-year-old woman presents to the emergency department with severe left lower abdominal pain, vaginal spotting, and dizziness. Her last menstrual period was 7 weeks ago. Vital signs show BP 90/60 mmHg, pulse 110 bpm, and temperature 98.6°F. Transvaginal ultrasound reveals an empty uterus and a 3.5 cm mass in the left fallopian tube with free fluid in the pelvis. The nurse is preparing for immediate surgical intervention. What is the priority nursing action?

This patient shows signs of a ruptured ectopic pregnancy with hemorrhage (hypotension, tachycardia, free fluid). The priority is establishing large-bore IV access for fluid resuscitation to prevent hypovolemic shock, as it addresses the immediate life-threatening circulatory compromise.

Clinical Context and Pathophysiology
This patient presents with a classic triad of ectopic pregnancy: amenorrhea (last menstrual period 7 weeks ago), unilateral lower abdominal pain, and vaginal spotting. The transvaginal ultrasound findings confirm a ruptured left tubal ectopic pregnancy — the uterus is empty, a 3.5 cm mass is visualized in the left fallopian tube, and free fluid (blood) is noted in the pelvis. Her vital signs — BP 90/60 mmHg (hypotension) and pulse 110 bpm (tachycardia) — indicate she is already in hypovolemic shock from intra-abdominal hemorrhage. In ectopic pregnancy, the growing embryo erodes into maternal blood vessels as the fallopian tube stretches and eventually ruptures, leading to rapid, life-threatening blood loss into the peritoneal cavity. This is a maternal near-miss (MNM) situation — a severe acute maternal morbidity where the woman nearly dies but survives a life-threatening obstetric complication ^[1][4]. The immediate threat is not pain or the need for consent, but hemodynamic collapse from ongoing hemorrhage.

Priority Nursing Action and Rationale
The correct answer is Option 2: Establish large-bore IV access and prepare for fluid resuscitation. In the hierarchy of emergency management for hemorrhagic shock, restoring circulating volume to maintain organ perfusion is the immediate priority. A large-bore IV (18-gauge or larger) allows rapid infusion of isotonic crystalloids (e.g., Lactated Ringer’s or normal saline) and blood products. The goal is to stabilize the patient for the operating room; surgical intervention is the definitive treatment to stop the bleeding, but the patient must survive the transport to the OR. This aligns with the principle that cases of ectopic pregnancy presenting with hemodynamic instability require urgent intervention with simultaneous arrangement of transport and blood transfusion ^[3].

Analysis of Other Options
- Option 1 (Administer prescribed analgesics): Pain management is important but secondary. Narcotic analgesics can cause vasodilation and further drop blood pressure in an already hypotensive patient. Addressing pain before volume status is dangerous in shock.
- Option 3 (Position in Trendelenburg): The Trendelenburg position (head down, feet up) was historically used for shock but is no longer recommended. It does not improve cardiac output, can impair respiratory mechanics by pushing abdominal contents against the diaphragm, and may increase the risk of aspiration. The current standard is to keep the patient supine or in a modified left lateral tilt if pregnancy is advanced, but the priority is fluid volume.
- Option 4 (Obtain informed consent): While informed consent is legally and ethically required before surgery, it is not the nurse’s most immediate action in a life-threatening emergency. The surgeon typically obtains consent. The nurse’s priority is to participate in the resuscitation that keeps the patient alive long enough for consent and surgery to occur. Delaying fluid resuscitation to obtain a signature would worsen the patient’s outcome.

Clinical Reasoning and Evidence Integration
The acute abdomen, as seen here, is a life-threatening entity requiring immediate diagnostic evaluation and treatment; 15-20% of emergency patients with acute abdominal pain need urgent surgical or interventional treatment . In this case, the sudden onset of severe pain with hemodynamic instability and evidence of free fluid on ultrasound confirms a surgical emergency. The nurse’s role is to recognize the signs of shock and act on the ABCs (Airway, Breathing, Circulation). Circulation takes precedence here: large-bore IV access and aggressive fluid resuscitation are the foundational nursing interventions that bridge the patient to definitive surgical control of the hemorrhage. The study on maternal near-miss cases emphasizes that prompt, structured management of these life-threatening conditions is critical to preventing maternal death ^[1][4].