A 32-year-old woman at 34 weeks gestation presents to the emergency department with severe abdominal pain and vaginal bleeding. Assessment reveals a rigid, tender abdomen and fetal heart rate of 90 bpm. What is the nurse's highest priority action?
1Prepare for immediate cesarean delivery✓ 정답
2Insert two large-bore IV catheters for fluid resuscitation
3Apply continuous fetal monitoring
4Obtain blood samples for coagulation studies
해설
With fetal bradycardia (90 bpm) and signs of severe abruptio placentae, immediate cesarean delivery is the priority to save maternal and fetal lives. Other interventions are secondary in this life-threatening emergency.
Clinical Judgment
This question assesses the ability to identify severe fetal bradycardia and maternal shock signs in the Recognize Cues stage, and then determine immediate life-saving measures through Prioritize Hypotheses and Generate Solutions. The key cues are severe abdominal pain and vaginal bleeding, a rigid and tender abdomen, and the critical fetal heart rate of 90 bpm. This indicates severe fetal hypoxia and maternal hemorrhage due to Abruptio Placentae. In this situation, the top-priority hypothesis is "an obstetric emergency threatening the lives of both fetus and mother," and the top-priority solution to resolve this is an emergency cesarean section, which can immediately deliver the fetus to stop the hypoxia and control the bleeding. All other interventions (IV access, monitoring, tests) should be performed in the process of preparing for or supporting this life-saving measure.
Memory Tip
Remember the formula: Fetal bradycardia + Abruptio Placentae = Immediate delivery. Abruptio with Bradycardia means C-section Alert (ABC). The clearest signal that the fetus is in danger is the fetal heart rate.
KR vs US
In Korea, even if the fetal condition is critical, there may be cases where conservative treatment is attempted or more time is spent consulting with the family. However, from the US NGN/CJMM perspective, fetal bradycardia is an absolute indication for immediate delivery, and the nurse must independently begin preparing the operating room while simultaneously reporting to the physician. The option of 'waiting for a doctor's order' could be the worst possible choice.
임상 시나리오
Clinical Practice Guide
Nurse's role when suspecting severe placental abruption:
1. Immediately report to the physician and notify the operating room/delivery room.
2. Monitor maternal vital signs, oxygen saturation, and amount of bleeding.
3. Prepare for large-bore (16-18G) IV access and fluid administration (see Box 2).
4. Apply continuous fetal monitoring (see Box 3).
5. Collect blood samples (blood type, crossmatch, CBC, coagulation studies) to assess for coagulopathy (DIC) (see Box 4).
All of this should be done concurrently during preparation for cesarean section. Activating the system to achieve the fastest possible delivery is the nurse's core clinical judgment.
Caution
A common pitfall in SATA (Select All That Apply) questions is "selecting all because they are all important interventions." In CJMM, they ask about priority. Look for "the first thing to do," "priority action," or "the most important thing." In this case, securing IV access or drawing labs are not actions that delay delivery, but actions that should be done concurrently while preparing for delivery.
핵심 개념
Abruptio Placentae (태반조기박리) — A condition in which the placenta, normally attached to the uterine wall, separates prematurely before delivery. It is accompanied by concealed (hidden) or obvious vaginal bleeding, abdominal pain, and uterine tenderness, and is an emergency that can threaten the lives of both the mother and fetus.
Fetal Bradycardia (태아 서맥) — A condition where the fetal baseline heart rate persistently decreases below 110 bpm. Generally, a rate below 100 bpm suggests severe hypoxia and is an emergency signal requiring immediate intervention (delivery).
Cesarean Delivery (제왕절개 분만) — Surgical procedure that delivers the fetus by incising the abdomen and uterus. It is performed for rapid delivery in situations that threaten the life of the mother or fetus, such as fetal distress, placental abruption, or umbilical cord prolapse.
Disseminated Intravascular Coagulation (DIC, 파종성 혈관내 응고) — Major complications of placental abruption. A life-threatening condition where tissue factor is released due to bleeding, leading to systemic microvascular thrombosis and simultaneous consumption of coagulation factors.
Uterine Hypertonus (자궁 긴장과다) — A condition that can occur when a hematoma behind the placenta irritates the uterine wall during placental abruption. It gives a feeling of the uterus being continuously hard and contracted (board-like abdomen) without relaxing.