# A pregnant client at 32 weeks gestation is admitted with severe preeclampsia and develops disseminated intravascular coagulation (DIC). Which nursing action should be the highest priority?

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> subject: Maternal Newborn Health

## 문제

A pregnant client at 32 weeks gestation is admitted with severe preeclampsia and develops disseminated intravascular coagulation (DIC). Which nursing action should be the highest priority?

## 보기

1. Monitor for signs of bleeding and implement bleeding precautions **✔ 정답**
2. Prepare for immediate cesarean delivery under general anesthesia
3. Administer prescribed anticoagulant therapy as ordered
4. Obtain blood samples for coagulation studies and labs

**정답: 1**

## 해설

In DIC, the priority is monitoring for bleeding and implementing bleeding precautions due to consumption of clotting factors and platelets. Immediate delivery, anticoagulant therapy, and coagulation studies are important but secondary to managing the immediate bleeding risk.

## 심화 해설

Understanding the Pathophysiology: The Link Between Severe Preeclampsia and DIC

In severe preeclampsia, widespread endothelial dysfunction leads to vasospasm and placental hypoperfusion. This damaged endothelium triggers a massive release of thromboplastin (tissue factor) into the maternal circulation, activating the extrinsic coagulation cascade. This process consumes clotting factors and platelets faster than the body can produce them, a state known as disseminated intravascular coagulation (DIC). The result is a paradoxical clinical picture: microthrombi form in small vessels (causing end-organ damage), while simultaneously, the depletion of clotting factors and platelets leads to a profound risk of hemorrhage. The underlying principle of management, as highlighted in the context of obstetric emergencies complicated by DIC, is that "early management of both underlying etiology... and subsequent complications (DIC) is crucial to minimize morbidity and mortality" . In preeclampsia, the underlying etiology is the diseased placenta, but until delivery is safely achievable, managing the immediate life-threatening complication—the hemorrhagic tendency—takes precedence.

Analyzing the Priority Nursing Action

The question asks for the highest priority nursing action. Using the ABC (Airway, Breathing, Circulation) and safety-first framework, a patient with DIC is at immediate risk of death from hemorrhage due to circulatory collapse.

- Correct Answer: Monitor for signs of bleeding and implement bleeding precautions. In the acute phase of DIC, the patient is in a hypocoagulable state due to the consumption of platelets and clotting factors. The nurse's immediate priority is to ensure patient safety by preventing and detecting bleeding. This includes assessing for overt signs (e.g., oozing from IV sites, petechiae, hematuria) and covert signs (e.g., altered mental status suggesting intracranial hemorrhage, tachycardia, and hypotension). Implementing bleeding precautions—such as using a soft-bristled toothbrush, avoiding intramuscular injections, and applying prolonged pressure to venipuncture sites—directly mitigates the risk of catastrophic hemorrhage. This aligns with the critical care principle of managing the "subsequent complications" of the obstetric trigger .

- Why the other options are not the highest priority:

- Option 2 (Prepare for immediate cesarean delivery): While delivery is the definitive treatment for severe preeclampsia, performing major abdominal surgery on a patient with active, uncontrolled DIC is extremely dangerous and could lead to fatal intraoperative hemorrhage. The patient must first be stabilized, and the coagulopathy must be addressed with blood product replacement before any surgical intervention is considered. The underlying etiology is important, but the immediate life-threatening complication must be controlled first .

- Option 3 (Administer prescribed anticoagulant therapy): This is contraindicated in the acute, hemorrhagic phase of DIC. Anticoagulants like heparin are reserved for the rare cases where thrombosis (not hemorrhage) is the dominant clinical feature. In the typical obstetric DIC scenario driven by preeclampsia, the patient is bleeding, and giving an anticoagulant would be catastrophic.

- Option 4 (Obtain blood samples for coagulation studies and labs): This is an important and necessary action to confirm the diagnosis and guide replacement therapy. However, it is not the highest priority action. In the hierarchy of nursing care, ensuring immediate physical safety (preventing a fall or a major bleed) takes precedence over a diagnostic procedure. Furthermore, venipuncture itself is a risk for bleeding in these patients, and the nurse must apply the principles of bleeding precautions while obtaining these samples.

Clinical Application and Test-Taking Strategy

For NCLEX-RN questions involving DIC, always first determine the patient's primary clinical presentation. In obstetric-related DIC, the presentation is overwhelmingly hemorrhagic. The priority nursing concepts are safety and perfusion. The correct nursing action will always focus on protecting the patient from injury (bleeding) and monitoring for signs of hypovolemic shock. A study on maternal near-miss cases reinforces that severe acute maternal morbidity, including hemorrhage, requires immediate and focused management to prevent mortality . The nurse's role is to recognize that before any curative treatment (delivery) or diagnostic steps (lab draws), the patient's immediate safety from a life-threatening hemorrhage must be secured.

## 임상 시나리오

Clinical Scenario

A 28-year-old G1P0 at 32 weeks gestation with severe preeclampsia develops acute disseminated intravascular coagulation (DIC). Vital signs: BP 160/110 mmHg, HR 112 bpm, RR 24/min, O2 sat 95% on room air. Oozing noted from IV sites and gums. Platelets 45,000/uL, fibrinogen 80 mg/dL, PT/PTT prolonged, D-dimer elevated.

Nursing Priorities

- **Safety First:** Initiate bleeding precautions immediately. Use a soft-bristled toothbrush, avoid rectal procedures/temperatures, apply pressure dressings to any puncture sites, and pad bed rails.

- **Monitoring:** Perform serial assessments for overt and occult bleeding. Check all body fluids (urine, stool, emesis) for blood. Monitor for petechiae, purpura, and expanding hematomas. Neurologic checks for signs of intracranial hemorrhage.

- **Circulation Support:** Establish two large-bore IV lines. Anticipate orders for blood product replacement (fresh frozen plasma, cryoprecipitate, platelets) rather than anticoagulants. Maintain strict intake and output.

Clinical Management

- **Treat Underlying Cause:** Prepare for delivery once the patient is hemodynamically stable. Magnesium sulfate administration continues for seizure prophylaxis. Continuous fetal monitoring is essential.

- **Lab Follow-up:** Draw coagulation panels (PT/PTT, fibrinogen, D-dimer, platelets) as ordered, but do not delay safety interventions to obtain labs. Apply prolonged pressure after venipuncture.

- **Psychosocial Care:** Provide clear, calm explanations to reduce anxiety. Keep the patient and family informed of the plan, as the rapid deterioration can be extremely frightening.

## 핵심 개념

- **Disseminated Intravascular Coagulation (DIC)** — An acquired syndrome characterized by widespread activation of coagulation, leading to microthrombi formation and simultaneous depletion of clotting factors and platelets, resulting in severe bleeding risk.
- **Severe Preeclampsia** — A hypertensive disorder of pregnancy involving endothelial dysfunction and vasospasm, which can trigger DIC through the release of thromboplastin from a hypoperfused placenta.
- **Bleeding Precautions** — Nursing interventions to prevent hemorrhage, including using soft toothbrushes, avoiding venipuncture when possible, applying prolonged pressure to puncture sites, and preventing falls.

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