# A 32-year-old gravida 2, para 1 client at 34 weeks gestation presents to the labor and delivery unit with sudden onset of severe abdominal pain and vaginal bleeding. The client reports the pain started suddenly about 30 minutes ago and describes it as constant and severe. She has a history of cocaine use but denies recent use. Physical examination reveals a rigid, tender abdomen and dark red vaginal bleeding. Vital signs are: BP 90/60 mmHg, HR 120 bpm, RR 24/min. The fetal heart rate shows late decelerations with decreased variability. What is the nurse's highest priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542935 > language: ko > subject: Maternal Newborn Health ## 문제 A 32-year-old gravida 2, para 1 client at 34 weeks gestation presents to the labor and delivery unit with sudden onset of severe abdominal pain and vaginal bleeding. The client reports the pain started suddenly about 30 minutes ago and describes it as constant and severe. She has a history of cocaine use but denies recent use. Physical examination reveals a rigid, tender abdomen and dark red vaginal bleeding. Vital signs are: BP 90/60 mmHg, HR 120 bpm, RR 24/min. The fetal heart rate shows late decelerations with decreased variability. What is the nurse's highest priority action? The client reports the pain started suddenly about 30 minutes ago and describes it as constant and severe. She has a history of cocaine use but denies recent use. Physical examination reveals a rigid, tender abdomen and dark red vaginal bleeding. ## 보기 1. Prepare for immediate cesarean delivery **✔ 정답** 2. Administer IV fluid bolus to stabilize blood pressure 3. Position the client in left lateral position 4. Obtain blood samples for coagulation studies **정답: 1** ## 해설 This scenario describes placental abruption, a life-threatening obstetric emergency requiring immediate delivery. The fetal heart rate pattern indicates severe fetal compromise, making immediate cesarean delivery the highest priority to save both maternal and fetal lives. Other options are supportive but secondary to delivery. ## 심화 해설 Clinical Presentation Analysis This client presents with a classic triad of placental abruption: sudden onset of severe, constant abdominal pain, dark red vaginal bleeding, and a rigid, tender uterus. The pathophysiology involves premature separation of the placenta from the uterine wall before delivery, leading to hemorrhage at the decidual-placental interface [1]. The constant, severe pain described by the client results from blood infiltrating the myometrium and stretching the uterine serosa, which distinguishes abruption from other causes of bleeding such as placenta previa. The maternal vital signs are critically concerning: BP 90/60 mmHg indicates hypotension, and HR 120 bpm reflects compensatory tachycardia. These findings, combined with the rigid abdomen, suggest significant concealed or revealed blood loss and possible progression toward hypovolemic shock. The fetal heart tracing reveals late decelerations with decreased variability, indicating uteroplacental insufficiency and fetal hypoxia. In placental abruption, the separated portion of the placenta cannot participate in gas exchange, and ongoing maternal hemorrhage further compromises uterine blood flow [1]. Priority Action Rationale The highest priority action is to prepare for immediate cesarean delivery. The rationale is grounded in the dual threat to both maternal and fetal life. From the maternal perspective, the rigid, tender abdomen with hypotension signals a severe abruption likely involving significant retroplacental clot formation and blood loss. Ongoing hemorrhage can precipitate disseminated intravascular coagulation (DIC), a catastrophic complication where consumption of clotting factors and platelets leads to both thrombosis and uncontrolled bleeding [3]. In placental abruption, thromboplastin released from the damaged decidua enters the maternal circulation, triggering the extrinsic coagulation cascade and consumptive coagulopathy, with platelet counts falling dramatically [3]. Delaying delivery allows this process to escalate. From the fetal perspective, the late decelerations and decreased variability indicate that the fetus is already compromised and will not tolerate continued intrauterine existence. The management dilemma described in the literature—balancing prompt delivery for maternal benefit against delayed delivery for fetal benefit—applies primarily to cases remote from term [1]. At 34 weeks gestation, with a viable fetus already showing signs of severe distress, immediate delivery serves both patients. The fetus has a higher probability of intact survival with prompt extraction and neonatal resuscitation than with continued exposure to a progressively failing placenta. Why Other Options Are Not the Priority Administering an IV fluid bolus (Option 2) is an important resuscitative measure for the hypotensive mother, but it is a temporizing action that does not address the underlying cause. Fluid resuscitation should occur concurrently with, not instead of, preparation for definitive surgical management. The source of hemorrhage—the separating placenta—cannot be controlled without delivery. Positioning the client in left lateral position (Option 3) is a standard intervention to relieve aortocaval compression and improve uterine blood flow. However, in the context of a severe abruption with maternal shock and a non-reassuring fetal heart tracing, this maneuver alone will not reverse the pathophysiology. The primary insult is placental separation and hemorrhage, not vena caval compression. Obtaining blood samples for coagulation studies (Option 4) is essential for diagnosing DIC and guiding blood product replacement, but it does not take precedence over arranging the definitive intervention. The clinical picture of a rigid abdomen, hypotension, and dark red bleeding already provides sufficient diagnostic certainty to proceed with emergency delivery. Coagulation studies can be drawn while the operating room is being prepared, but they should not delay the cesarean section. The literature emphasizes that in the presence of maternal shock or consumption coagulopathy, prompt delivery is the cornerstone of management [1]. Surgical metrics from emergency cesarean deliveries for placental abruption demonstrate that minimizing decision-to-delivery time is critical for both maternal and neonatal outcomes .References (research sources) - [1]Safety and efficacy of atosiban for fetomaternal resuscitation following severe placental abruption in preparation for an emergency cesarean section: a narrative review.Research articleOdendaal HJ, Lamont RF. (2026) · DOI: 10.1080/14740338.2025.2580313 - [3]Peripartum Vascular Calamities: Placental Abruption and Amniotic Fluid Emboli.Research articleWolfovitz A, Brenner B, Solt I. (2026) · DOI: 10.1055/a-2877-3436 ## 임상 시나리오 Clinical Scenario A 32-year-old G2P1 at 34 weeks presents with sudden, severe, constant abdominal pain, dark red vaginal bleeding, and a rigid, tender uterus. Maternal vitals show hypotension (90/60 mmHg) and tachycardia (120 bpm). Fetal tracing reveals late decelerations with decreased variability. Priority Nursing Action The highest priority is to **prepare for immediate cesarean delivery**. This is a dual emergency: maternal hemodynamic instability from concealed hemorrhage and fetal distress from uteroplacental insufficiency. Definitive treatment requires delivery to stop the hemorrhage and restore fetal oxygenation. Clinical Reasoning - **Recognition:** The classic triad of pain, dark bleeding, and a rigid uterus confirms placental abruption. Hypotension and tachycardia signal significant blood loss and impending shock. - **Fetal Assessment:** Late decelerations with minimal variability indicate severe fetal hypoxia. The separated placenta cannot perform gas exchange, and delay will result in fetal demise. - **Maternal Priority:** A rigid, tender uterus suggests a Couvelaire uterus from blood extravasation. The hemorrhage must be surgically controlled; fluid resuscitation alone is insufficient. - **Team Activation:** Notify the obstetrician, anesthesiologist, and neonatal team simultaneously. Prepare the operating room, blood products, and neonatal resuscitation equipment. Nursing Interventions While Preparing for C-Section - Insert two large-bore IV lines and begin fluid resuscitation with crystalloids as ordered. - Administer oxygen via non-rebreather mask at 10-15 L/min to optimize maternal oxygenation. - Position the client in a left lateral tilt to relieve aortocaval compression and improve venous return. - Draw blood for type and crossmatch, complete blood count, and coagulation profile (including fibrinogen). - Insert an indwelling urinary catheter to monitor output and assess renal perfusion. - Continuously monitor maternal vital signs and fetal heart rate until transfer to the operating room. Postoperative Considerations After delivery, monitor closely for postpartum hemorrhage, as abruption increases the risk of uterine atony and disseminated intravascular coagulation (DIC). Assess fundal tone, lochia, and vital signs frequently. Provide emotional support and debriefing, as this is a traumatic experience. ## 핵심 개념 - **Placental Abruption** — Premature separation of the placenta from the uterine wall before delivery, causing hemorrhage and potentially leading to fetal hypoxia and maternal shock. - **Late Decelerations** — A fetal heart rate pattern where the deceleration occurs after the peak of a contraction, indicating uteroplacental insufficiency and fetal hypoxia. - **Uteroplacental Insufficiency** — A condition where blood flow and gas exchange across the placenta are reduced, compromising fetal oxygenation and causing heart rate abnormalities. ## 같은 주제 문제 - [A 28-year-old gravida 1, para 0 client at 38 weeks gestation presents to the labor and del…](https://mymerci.kr/pages/nclex_q.php?qn_id=542929) - [A 32-year-old gravida 2, para 1 client at 28 weeks gestation presents to the labor and del…](https://mymerci.kr/pages/nclex_q.php?qn_id=542930) - [A 28-year-old gravida 3, para 2 client at 34 weeks gestation presents to the labor and del…](https://mymerci.kr/pages/nclex_q.php?qn_id=542931) - [A 35-year-old gravida 2, para 1 client at 36 weeks gestation presents to the labor and del…](https://mymerci.kr/pages/nclex_q.php?qn_id=542932) - [A 32-year-old gravida 2, para 1 client at 34 weeks gestation presents to the labor and del…](https://mymerci.kr/pages/nclex_q.php?qn_id=542933) - [A 28-year-old gravida 1, para 0 client at 28 weeks gestation presents to the labor and del…](https://mymerci.kr/pages/nclex_q.php?qn_id=542934) - [A 32-year-old gravida 2, para 1 client at 34 weeks gestation presents to the labor and del…](https://mymerci.kr/pages/nclex_q.php?qn_id=542936) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._