# A pregnant client at 36 weeks gestation is admitted to the labor and delivery unit with suspected placental abruption. Which assessment finding would be the priority for the nurse to monitor? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542817 > language: ko > subject: Maternal Newborn Health ## 문제 A pregnant client at 36 weeks gestation is admitted to the labor and delivery unit with suspected placental abruption. Which assessment finding would be the priority for the nurse to monitor? The nurse must prioritize assessment findings that indicate maternal and fetal compromise in placental abruption. ## 보기 1. Fetal heart rate patterns and variability **✔ 정답** 2. Maternal blood pressure and pulse 3. Uterine contraction frequency and intensity 4. Vaginal bleeding amount and characteristics **정답: 1** ## 해설 Fetal heart rate monitoring is the priority in placental abruption due to compromised uteroplacental circulation leading to fetal hypoxia. Other assessments (maternal BP/pulse, contractions, vaginal bleeding) are important but secondary to fetal well-being. ## 심화 해설 Understanding the Priority in Placental Abruption When a client presents with suspected placental abruption, the nurse must rapidly identify the assessment finding that provides the most immediate insight into fetal well-being and the potential for imminent decompensation. The premature separation of the placenta from the uterine wall compromises the fetal oxygen supply, making the fetal heart rate (FHR) the most sensitive and critical indicator of fetal status. While all the listed options are important components of the overall assessment, monitoring fetal heart rate patterns and variability is the priority because it directly reflects the impact of the abruption on the fetus, guiding urgent interventions such as expedited delivery. Why Fetal Heart Rate is the Priority The pathophysiology of placental abruption involves the disruption of the maternal-fetal vascular interface. As the placenta detaches, the surface area available for gas exchange and nutrient transfer decreases. This leads to a progressive decline in fetal oxygenation, which is immediately manifested as changes in the FHR tracing. The nurse must vigilantly monitor for late decelerations, decreased or absent variability, and fetal tachycardia or bradycardia, as these are signs of fetal hypoxemia and acidosis. According to the provided evidence, the clinical trajectory for placental abruption can be severe and rapid, especially in concealed cases where vaginal bleeding is absent, making FHR monitoring the only continuous window into the fetal condition . The decision for prompt delivery, as highlighted in the management of severe hypertensive disorders with abruption, is often predicated on a non-reassuring fetal status detected through this monitoring . Analyzing the Other Options - Maternal blood pressure and pulse: These are critical for assessing maternal hemodynamic stability, as a significant abruption can lead to hypovolemic shock. However, maternal vital signs can remain deceptively stable even when the fetus is in severe distress. A concealed abruption, for instance, may not immediately cause maternal hypotension or tachycardia, yet the fetus could be profoundly hypoxic . Therefore, while essential, this assessment does not provide the most direct and early evidence of fetal compromise. - Uterine contraction frequency and intensity: Placental abruption often presents with a hypertonic uterus or high-frequency, low-intensity contractions. While this finding supports the diagnosis and indicates uterine irritability, it is not a direct measure of fetal oxygenation. The primary concern with increased uterine activity is its potential to further compromise an already stressed fetus, an effect that is best evaluated by observing the FHR response to those contractions. - Vaginal bleeding amount and characteristics: The amount of external bleeding is notoriously unreliable in predicting the severity of a placental abruption. In a concealed abruption, blood is trapped behind the placenta, and there may be minimal or no visible vaginal bleeding, yet the degree of separation and fetal distress can be catastrophic . A study on normotensive pregnancies also implies that risk factors like small-for-gestational-age can be associated with abruption, independent of the overt clinical presentation . Therefore, the nurse cannot use visible blood loss as a primary gauge of fetal safety. The nurse's immediate priority is to advocate for the fetus by continuously assessing the FHR pattern. This data is paramount for the healthcare team to determine if the fetal reserve is being exhausted and if emergent delivery is necessary to prevent irreversible hypoxic injury. ## 임상 시나리오 Clinical Scenario A 32-year-old G2P1 at 36 weeks gestation arrives with sudden onset of sharp, constant abdominal pain and dark vaginal bleeding. She reports no recent trauma. Uterus is firm and tender with a board-like consistency upon palpation. Vital signs: BP 150/90, HR 110, RR 22. Fetal heart rate baseline is 170 bpm with minimal variability and recurrent late decelerations. Priority Nursing Actions - Place client in lateral position and administer oxygen at 10 L/min via non-rebreather mask. - Initiate continuous electronic fetal monitoring; notify provider immediately of Category III tracing. - Insert two large-bore IV lines and begin fluid resuscitation with Lactated Ringer's as ordered. - Prepare for emergency cesarean section: hold anticoagulants, send type and crossmatch, ensure blood products are available. Key Assessment Findings - **FHR monitoring:** Loss of variability, late decelerations, or bradycardia indicate severe fetal acidemia and require immediate intervention. - **Uterine assessment:** Hypertonic, rigid uterus with persistent pain suggests a concealed abruption with retroplacental clot formation. - **Maternal hemodynamics:** Tachycardia and hypotension may be late signs of significant blood loss; monitor for signs of disseminated intravascular coagulation (DIC). Clinical Pearls The amount of external bleeding often underestimates the true blood loss in placental abruption. Fetal heart rate patterns are the earliest and most reliable indicator of fetal status. A Category III tracing with a viable fetus necessitates delivery within 30 minutes. Always assess for Couvelaire uterus and DIC during cesarean section. ## 핵심 개념 - **Placental Abruption** — Premature separation of the placenta from the uterine wall before delivery, compromising fetal oxygen supply. - **Fetal Heart Rate Variability** — Fluctuations in the baseline fetal heart rate that indicate a functioning autonomic nervous system and adequate oxygenation. - **Late Decelerations** — FHR decreases that begin after the peak of a contraction, indicating uteroplacental insufficiency and fetal hypoxemia. - **Concealed Abruption** — Placental separation where blood is trapped behind the placenta, showing no visible vaginal bleeding despite severe compromise. - **Uteroplacental Insufficiency** — A decline in blood flow and oxygen transfer across the placenta, leading to fetal distress. ## 같은 주제 문제 - [A pregnant client at 32 weeks gestation is admitted to the labor and delivery unit with su…](https://mymerci.kr/pages/nclex_q.php?qn_id=542818) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._