# A 35-year-old woman at 36 weeks gestation presents to the emergency department with sudden onset of severe abdominal pain and vaginal bleeding. Her vital signs are: BP 100/70 mmHg, HR 110 bpm, RR 22/min, and fetal heart rate shows variable decelerations. The nurse suspects placental abruption. What is the priority nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542845 > language: ko > subject: Maternal Newborn Health ## 문제 A 35-year-old woman at 36 weeks gestation presents to the emergency department with sudden onset of severe abdominal pain and vaginal bleeding. Her vital signs are: BP 100/70 mmHg, HR 110 bpm, RR 22/min, and fetal heart rate shows variable decelerations. The nurse suspects placental abruption. What is the priority nursing intervention? ## 보기 1. Perform a vaginal examination to assess cervical dilation 2. Administer terbutaline to stop uterine contractions 3. Position the patient in Trendelenburg position to improve circulation 4. Establish large-bore IV access and prepare for emergency cesarean delivery **✔ 정답** **정답: 4** ## 해설 Establishing large-bore IV access and preparing for emergency cesarean delivery is the priority to manage maternal hemodynamic instability and fetal compromise in suspected placental abruption. Other interventions are contraindicated or less urgent. ## 심화 해설 Clinical Presentation Analysis The patient presents with a classic triad of placental abruption: sudden severe abdominal pain, vaginal bleeding, and signs of fetal distress (variable decelerations). Her vital signs show BP 100/70 mmHg and HR 110 bpm, which indicate maternal compensatory tachycardia in response to blood loss and potential hypovolemic shock. The fetal heart rate pattern with variable decelerations suggests umbilical cord compression or uteroplacental insufficiency, both of which are immediate threats to fetal oxygenation. Why Option 4 is the Priority In the context of suspected placental abruption with maternal hemodynamic instability and non-reassuring fetal status, the priority is to stabilize the mother and expedite delivery. Establishing large-bore IV access is the critical first step to initiate fluid resuscitation and prepare for potential blood product administration. Simultaneous preparation for an emergency cesarean delivery addresses the definitive treatment for the underlying cause. The pathophysiologic rationale is rooted in the fact that placental abruption can rapidly progress to disseminated intravascular coagulopathy (DIC). As noted in the ISTH registry communication, DIC in pregnancy is a severe maternal morbidity associated with short- and long-term complications, and its onset can be triggered by the release of thromboplastin from the disrupted placental bed into the maternal circulation . Without immediate surgical intervention to remove the source, the consumptive coagulopathy will worsen, increasing the risk of massive hemorrhage. Analysis of Incorrect Options **Option 1: Perform a vaginal examination to assess cervical dilation.** A digital vaginal examination is contraindicated when placental abruption is suspected, particularly if there is a co-existing placenta previa that has not been ruled out. The manipulation can disrupt a low-lying placenta, provoke catastrophic hemorrhage, and accelerate the coagulopathic process by introducing more tissue factor into the bloodstream . The priority is not to assess cervical status but to prepare for operative delivery based on the clinical picture. **Option 2: Administer terbutaline to stop uterine contractions.** Terbutaline is a tocolytic agent used to suppress preterm labor. In the setting of a suspected abruption, suppressing contractions is not only futile but potentially dangerous. The hypertonic uterine activity often seen with abruption is a symptom of the underlying pathology, not a primary cause. Administering a tocolytic would delay definitive delivery, mask ongoing symptoms, and could lead to cardiovascular side effects in a patient who is already tachycardic and potentially hypovolemic. **Option 3: Position the patient in Trendelenburg position to improve circulation.** The Trendelenburg position is not the standard of care for suspected placental abruption. While it may transiently increase venous return, it does not address the underlying obstetric emergency and can compromise maternal respiratory function by pushing abdominal contents against the diaphragm. The lateral uterine displacement position is more appropriate to relieve aortocaval compression and optimize uteroplacental perfusion while preparations for surgery are underway. Pathophysiological and Clinical Integration The clinical decision-making here is driven by the understanding that placental abruption is a progressive, time-sensitive condition. The separation of the placenta from the uterine wall before delivery leads to hemorrhage at the decidual-placental interface. This blood can track behind the placenta (concealed hemorrhage) or escape through the cervix (revealed hemorrhage). The resultant retroplacental clot releases thromboplastin, which activates the extrinsic coagulation cascade, a primary mechanism for the development of DIC . The maternal tachycardia and borderline hypotension are early indicators of the shift from a compensated to a potentially decompensated hypovolemic state. The non-reassuring fetal heart rate pattern confirms that the fetal reserve is compromised, and the window for intervention is narrowing. Therefore, the nurse's immediate action must focus on securing vascular access for volume replacement and facilitating the rapid mobilization of the surgical team for an emergency cesarean delivery. ## 임상 시나리오 Clinical Guide: Placental Abruption This guide outlines the immediate nursing priorities when placental abruption is suspected, focusing on maternal stabilization and rapid delivery. Immediate Priorities - **Do Not Delay for Vaginal Exam:** A digital cervical examination is contraindicated as it can provoke catastrophic hemorrhage, especially if an undiagnosed placenta previa is present. - **Establish Vascular Access:** Insert two large-bore (16- or 18-gauge) intravenous lines immediately to initiate fluid resuscitation with crystalloids and prepare for blood product transfusion. - **Prepare for Emergency Cesarean:** The definitive treatment is delivery of the fetus and placenta. Activate the surgical team and prepare the patient for the operating room without delay. Maternal-Fetal Assessment - **Monitor for Shock:** Continuously assess for signs of hypovolemic shock, including tachycardia, hypotension, pallor, and altered mental status. The visible vaginal bleeding often underestimates the total blood loss, as blood can be concealed behind the placenta. - **Continuous Fetal Monitoring:** Observe for non-reassuring fetal heart rate patterns such as late decelerations, bradycardia, or loss of variability, which indicate worsening fetal hypoxia. - **Assess for DIC:** Monitor for oozing from IV sites, petechiae, or bleeding gums, as placental abruption is a major trigger for disseminated intravascular coagulopathy. Key Interventions to Avoid - **Tocolytics (e.g., Terbutaline):** Do not administer medications to stop contractions. In the presence of fetal distress and maternal instability, tocolysis is contraindicated and delays definitive care. - **Trendelenburg Position:** This position does not improve placental perfusion and may impair maternal ventilation. Maintain the patient in a lateral uterine displacement position to relieve aortocaval compression. ## 핵심 개념 - **Placental Abruption (태반조기박리)** — A condition in which the placenta partially or completely separates from the uterine wall prematurely before delivery. It is a life-threatening emergency for both mother and fetus, characterized by pain, bleeding, and uterine tenderness. - **Late Decelerations (늦은 감속)** — A deceleration of the fetal heart rate that begins after a uterine contraction and continues even after the contraction ends. It is a sign of fetal hypoxia due to placental insufficiency and must be reported immediately. - **Hemodynamic Instability (혈역학적 불안정)** — A condition where the heart fails to pump enough blood to the body, leading to low blood pressure (hypotension), rapid heart rate, and reduced peripheral perfusion. In this case, rapid fluid replacement is necessary. - **Emergency Cesarean Delivery (응급 제왕절개 분만)** — Surgical delivery performed in emergency situations that threaten the life of the mother or fetus. Indications include placental abruption, umbilical cord prolapse, and severe fetal distress. - **Large-bore IV Access (굵은 정맥로 확보)** — Generally, this involves inserting a large catheter, typically 14-16 gauge, into a vein. 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