# A nurse is assessing a 25-year-old woman who presents to the emergency department with complaints of sharp, unilateral pelvic pain and light vaginal bleeding. Which assessment finding would be most indicative of a ruptured ectopic pregnancy requiring immediate intervention?

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> subject: Maternal Newborn Health

## 문제

A nurse is assessing a 25-year-old woman who presents to the emergency department with complaints of sharp, unilateral pelvic pain and light vaginal bleeding. Which assessment finding would be most indicative of a ruptured ectopic pregnancy requiring immediate intervention?

## 보기

1. Positive pregnancy test with beta-hCG level of 1,500 mIU/mL
2. Orthostatic hypotension with a significant drop in blood pressure upon standing **✔ 정답**
3. Transvaginal ultrasound showing an empty uterus with no gestational sac
4. Serum progesterone level of 8 ng/mL

**정답: 2**

## 해설

Orthostatic hypotension indicates significant blood loss from rupture, requiring urgent surgery. Other findings support ectopic pregnancy diagnosis but do not signal immediate life-threat.

## 심화 해설

Clinical Context and Priority Setting

In the emergency department, a patient presenting with sharp unilateral pelvic pain and vaginal bleeding raises immediate concern for an ectopic pregnancy. While several diagnostic findings can support this diagnosis, the NCLEX-RN prioritization framework requires identifying the finding that signals a life-threatening complication: hemorrhagic shock from a rupture. The assessment finding that most directly indicates hemodynamic instability and the need for immediate intervention is orthostatic hypotension.

Analysis of Options

**Option 1:** A positive pregnancy test with a beta-hCG level of 1,500 mIU/mL confirms pregnancy and reaches the discriminatory zone where an intrauterine pregnancy should be visible on ultrasound. This finding supports the diagnostic workup but does not, by itself, indicate rupture or hemodynamic compromise.

**Option 2 (Correct):** Orthostatic hypotension is defined by a fixed difference in systolic BP (≥ 20 mmHg) or diastolic BP (≥ 10 mmHg) between supine (or seated) and standing positions [1]. In the context of a suspected ruptured ectopic pregnancy, this finding reflects significant intra-abdominal hemorrhage and intravascular volume depletion. The body's compensatory mechanisms are failing, and the drop in blood pressure upon standing is a critical, objective sign of impending cardiovascular collapse. This requires immediate intervention, such as large-bore IV access, fluid resuscitation, and preparation for surgery.

**Option 3:** A transvaginal ultrasound showing an empty uterus with no gestational sac is a key diagnostic criterion for an ectopic pregnancy, especially with a beta-hCG above the discriminatory zone. However, this is a diagnostic finding, not a direct indicator of rupture or active hemorrhage. A patient can have an unruptured ectopic pregnancy with this ultrasound finding and be hemodynamically stable.

**Option 4:** A serum progesterone level of 8 ng/mL is a non-diagnostic value that suggests an abnormal or non-viable pregnancy but does not confirm the location or indicate rupture. It is a supportive, not definitive, piece of the clinical picture.

Pathophysiology and Clinical Reasoning

A ruptured ectopic pregnancy leads to bleeding into the peritoneal cavity. As blood loss progresses, the patient develops hypovolemic shock. The autonomic nervous system initially compensates with vasoconstriction and tachycardia to maintain blood pressure when supine. However, this compensatory mechanism is stressed when the patient stands, causing venous pooling and a drop in cardiac output. The resulting orthostatic hypotension is a late and alarming sign of significant volume loss [1]. While the provided reference on orthostatic hypotension [1] discusses its general pathophysiology and association with adverse outcomes, the clinical principle is directly applicable here: a significant postural blood pressure drop in a patient with a suspected bleeding source is a critical finding that demands immediate action. The other options represent diagnostic clues, but the orthostatic vital sign change is the most direct measure of the patient's current physiological threat.

References (research sources)

- [1]A Review of Clinical Trial and Meta-Analyses of BP Treatment Strategies for Patients with Orthostatic Hypotension: Blood Pressure Management in Patients with Hypertension and Orthostatic Hypotension.RCT/clinical trialRajesh S, Lee GR, Gao KJ, Verma A, Juraschek SP. (2026) · DOI: 10.1007/s11906-026-01368-5

## 임상 시나리오

Clinical Practice Guide: Suspected Ruptured Ectopic Pregnancy

When a patient presents with unilateral pelvic pain and vaginal bleeding, immediately assess for hemodynamic stability. Orthostatic vital signs are critical; a systolic drop of 20 mmHg or diastolic drop of 10 mmHg upon standing indicates significant volume loss from intra-abdominal hemorrhage.

Prioritize interventions: establish two large-bore IV lines, initiate isotonic fluid resuscitation, type and crossmatch blood, and prepare for surgical intervention. Do not delay care for serial beta-hCG or ultrasound if the patient shows signs of shock.

A transvaginal ultrasound showing an empty uterus with a beta-hCG above the discriminatory zone supports the diagnosis but is not required before stabilizing the patient. Continuous monitoring of vital signs and urine output is essential to detect deterioration.

## 핵심 개념

- **Orthostatic Hypotension** — A drop in systolic BP of at least 20 mmHg or diastolic BP of at least 10 mmHg upon standing, indicating volume depletion or autonomic dysfunction.
- **Ectopic Pregnancy** — Implantation of a fertilized egg outside the uterine cavity, most commonly in the fallopian tube, which can lead to life-threatening rupture and hemorrhage.
- **Discriminatory Zone** — The beta-hCG level (typically 1,500-2,000 mIU/mL) above which a gestational sac should be visible on transvaginal ultrasound if the pregnancy is intrauterine.

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