# A 35-year-old gravida 2, para 1 client at 36 weeks gestation presents to the labor and delivery unit with sudden onset of severe abdominal pain and vaginal bleeding. Assessment reveals a rigid, board-like abdomen, fetal heart rate of 90 bpm with minimal variability, and maternal vital signs: BP 90/60 mmHg, HR 120 bpm, RR 24/min. Ultrasound confirms complete placental abruption. What is the priority nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542932  
> language: ko  
> subject: Maternal Newborn Health

## 문제

A 35-year-old gravida 2, para 1 client at 36 weeks gestation presents to the labor and delivery unit with sudden onset of severe abdominal pain and vaginal bleeding. Assessment reveals a rigid, board-like abdomen, fetal heart rate of 90 bpm with minimal variability, and maternal vital signs: BP 90/60 mmHg, HR 120 bpm, RR 24/min. Ultrasound confirms complete placental abruption. What is the priority nursing intervention?

## 보기

1. Administer oxygen via nasal cannula at 2-4 L/min and position client in left lateral position
2. Insert two large-bore IV catheters and begin rapid fluid resuscitation with normal saline
3. Prepare for emergency cesarean delivery and notify the surgical team immediately **✔ 정답**
4. Apply external fetal monitoring and assess for uterine contractions every 15 minutes

**정답: 3**

## 해설

Complete placental abruption with fetal bradycardia and maternal shock requires emergency cesarean delivery to save both lives. Supportive measures like oxygen, IV fluids, and monitoring are secondary to immediate surgical intervention.

## 심화 해설

Clinical Judgment
This question assesses priority judgment in a Placental Abruption emergency that threatens the lives of both mother and fetus. The key point is that **both maternal and fetal conditions are rapidly deteriorating**. A fetal heart rate of 90 bpm indicates severe fetal bradycardia, signifying intrauterine hypoxia and immediate danger. The mother's hypotension, tachycardia, and rigid abdomen suggest progressive hemorrhage and shock. In this situation, the most urgent goal is to deliver the fetus to stop the hypoxia and remove the source of maternal bleeding (the abrupted placenta). Therefore, all other supportive interventions are **measures that should be performed on the way to the operating room**, and the priority is preparation for and execution of an immediate cesarean section.

Memory Tip
**A**bruption = **A**bsolute **A**dmission & **A**ction. When you see a "board-like abdomen + fetal bradycardia + signs of shock," think **immediate C-section**.

KR vs US
In Korea, there may be situations where aggressive fluid resuscitation and blood product administration are attempted first to stabilize the mother, even if the fetal condition is critical. However, from the US NGN/CJMM perspective, in a complete abruption scenario where both fetus and mother are compromised (dual compromise), the most effective intervention is considered to be **immediate delivery**. Delay dramatically increases the risk of fetal death and maternal DIC (Disseminated Intravascular Coagulation).

## 임상 시나리오

Clinical Practice Guide
When evaluating a patient suspected of having placental abruption, remember the "6P"s: Pain, Pressure, Placenta (placental issue), Poor fetal heart rate, Per vaginal bleeding, Preterm labor. All of these apply in this case.

Caution
A common pitfall in SATA (Select All That Apply) questions is being asked to choose "all necessary interventions." In this case, securing IV access, administering oxygen, and lateral positioning are all important, but **what the question is asking for is the 'single highest priority intervention'**. In life-threatening situations, *therapeutic interventions that remove the cause* always take precedence over *supportive interventions*.

## 핵심 개념

- **Placental Abruption (태반조기박리)** — Premature separation of the placenta from the uterine wall before delivery. A life-threatening emergency for both mother and fetus, characterized by painful vaginal bleeding, uterine tenderness, and fetal distress.
- **Fetal Bradycardia (태아 빈맥)** — Fetal baseline heart rate persistently below 110 bpm. Generally, below 100 bpm is considered severe and is a sign of intrauterine hypoxia.
- **Cesarean Delivery (제왕절개)** — Surgery to deliver a fetus through an incision in the abdomen and uterus. Performed to save lives in obstetric emergencies such as placental abruption, fetal distress, and umbilical cord prolapse.
- **Disseminated Intravascular Coagulation (DIC, 파종성 혈관내 응고)** — Major maternal complications of placental abruption. Tissue factor (thromboplastin) is released from the site of detachment, causing systemic microvascular coagulation, which simultaneously leads to consumptive coagulopathy and bleeding risk.
- **Board-like Abdomen (판자 같은 복부)** — A rigid abdomen felt hard due to tonic contraction of the abdominal wall muscles. This is a classic sign seen in severe intrauterine hemorrhage from placental abruption, reflecting uterine hypertonic contractions and peritoneal irritation.

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