# A 32-year-old woman at 34 weeks gestation presents to the emergency department with sudden onset of severe abdominal pain and vaginal bleeding. Assessment reveals a rigid, tender abdomen and fetal heart rate of 90 bpm. The nurse suspects abruptio placentae. What is the priority nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542949 > language: ko > subject: Maternal Newborn Health ## 문제 A 32-year-old woman at 34 weeks gestation presents to the emergency department with sudden onset of severe abdominal pain and vaginal bleeding. Assessment reveals a rigid, tender abdomen and fetal heart rate of 90 bpm. The nurse suspects abruptio placentae. What is the priority nursing intervention? ## 보기 1. Perform a vaginal examination to assess cervical dilation 2. Administer prescribed pain medication to reduce maternal discomfort 3. Prepare for immediate cesarean delivery and notify the surgical team **✔ 정답** 4. Position the patient in Trendelenburg position to improve fetal circulation **정답: 3** ## 해설 In abruptio placentae with fetal bradycardia and maternal hemorrhage, immediate cesarean delivery is the priority to prevent fetal death and maternal complications like DIC. Other interventions are supportive but secondary to emergency delivery. ## 심화 해설 Clinical Context and Pathophysiology The scenario describes a classic presentation of abruptio placentae: sudden, severe abdominal pain with a rigid, tender abdomen (indicating concealed or mixed hemorrhage with uterine hypertonus) and vaginal bleeding at 34 weeks gestation. The fetal heart rate of 90 bpm signifies severe fetal bradycardia and distress. The underlying pathophysiology involves premature separation of the placenta from the decidual basalis, leading to hemorrhage at the decidual-placental interface. This disrupts maternal-fetal gas exchange and can rapidly progress to fetal hypoxia and demise. From a maternal perspective, the retroplacental clot and extravasation of blood into the myometrium (Couvelaire uterus) cause the characteristic board-like rigidity and pain. The hemorrhage can also trigger a consumption coagulopathy, such as disseminated intravascular coagulation (DIC), which is a leading cause of maternal morbidity and mortality in these cases [1,2]. Prioritization and Critical Decision-Making In this emergency, the priority is to address the root cause of both maternal and fetal compromise: the abrupted placenta. The fetus is in immediate danger due to hypoxia, and the mother is at risk for hemorrhage and coagulopathy. The definitive treatment is to deliver the fetus and the placenta, thereby removing the source of hemorrhage and halting the consumption of clotting factors. Given the fetal bradycardia and the mother's unstable condition, an immediate cesarean delivery is indicated. The concept of a crash cesarean section applies here, where the goal is to achieve delivery as quickly as possible, ideally within a 30-minute decision-to-incision interval, to mitigate the risk of severe fetal acidemia, hypoxic-ischemic encephalopathy, or death [3]. The nurse’s priority action is to activate the chain of events for an emergent surgical delivery by preparing the patient and notifying the surgical and neonatal teams. Analysis of Incorrect Options - Option 1 (Perform a vaginal examination): This is contraindicated. In the context of a suspected abruptio placentae with active bleeding, a digital vaginal examination can disrupt a low-lying clot or further separate the placenta, precipitating catastrophic hemorrhage. The diagnosis is made clinically based on the classic triad of pain, bleeding, and a hypertonic uterus, not by assessing cervical dilation. - Option 2 (Administer prescribed pain medication): While pain management is important, it is not the priority. Furthermore, the administration of systemic opioids could mask the progression of symptoms and cause fetal respiratory depression if delivery occurs soon after. The primary analgesic for the severe pain of abruption is the resolution of the uterine hypertonus, which occurs only after delivery . - Option 4 (Position in Trendelenburg): The Trendelenburg position is not a primary intervention for abruptio placentae and can be counterproductive. It does not improve uteroplacental perfusion when the underlying problem is a physical separation of the placenta. The immediate priority is to optimize maternal hemodynamics with a left lateral tilt to relieve aortocaval compression and to prepare for rapid surgical intervention, not to place the patient head-down. Synthesis of Evidence and Nursing Implication The management of severe abruptio placentae involves a critical balance between maternal and fetal risks. While delaying delivery might be considered for a periviable fetus, at 34 weeks with signs of severe fetal distress and maternal hemodynamic instability, prompt delivery is the only course of action that serves the best interest of both patients . The nurse's role is to recognize the life-threatening nature of the condition, avoid harmful interventions like a vaginal exam, and function as a coordinator to expedite a crash cesarean section. This involves initiating preoperative checklists, establishing large-bore intravenous access for fluid resuscitation and potential blood product transfusion, inserting a Foley catheter, and ensuring the neonatal resuscitation team is immediately available, all while providing clear communication and emotional support to the patient and family [3].References (research sources) - [3]Crash caesarean section audit: an important tool for an obstetric unit to ensure safe quality care.Research articleNg YHG, Tan LK, Wright A. (2025) · DOI: 10.1186/s12884-025-08203-w ## 임상 시나리오 Clinical Management of Abruptio Placentae **Scenario:** A 32-year-old G3P2 at 34 weeks presents with acute severe abdominal pain, vaginal bleeding, a rigid uterus, and fetal bradycardia (FHR 90 bpm). Suspect grade 2-3 abruptio placentae with concealed hemorrhage. Immediate Actions (First 15 Minutes) - **Activate Massive Transfusion Protocol:** Notify the blood bank and prepare for massive transfusion. Abruptio placentae is a major risk factor for DIC and postpartum hemorrhage. - **Prepare for Emergency Cesarean Delivery:** This is the definitive treatment. Fetal bradycardia necessitates a decision-to-delivery interval of less than 30 minutes. Notify the obstetrician, anesthesiologist, neonatologist, and surgical team simultaneously. - **Secure IV Access:** Insert two large-bore (16-18 gauge) intravenous lines and initiate fluid resuscitation with warmed crystalloids (e.g., Lactated Ringer's) to maintain maternal blood pressure and urine output >30 mL/hr. - **Maternal-Fetal Monitoring:** Apply continuous electronic fetal monitoring and maternal vital signs every 5 minutes. Assess for signs of shock (tachycardia, hypotension, pallor) and uterine hypertonus. Key Contraindications - **No Vaginal Examination:** Do not perform a digital cervical exam. It can disrupt a clot over the cervix and precipitate catastrophic hemorrhage, especially if an undiagnosed placenta previa is present. - **No Trendelenburg Positioning:** Avoid this position as it can compromise maternal ventilation and does not improve uteroplacental perfusion. Keep the patient in a left lateral tilt to relieve aortocaval compression. Ongoing Management and Monitoring - **Laboratory Studies:** Send STAT labs: CBC, coagulation profile (PT, aPTT, fibrinogen), D-dimer, type and crossmatch for at least 4 units of packed red blood cells. - **Fibrinogen Monitoring:** A fibrinogen level below 200 mg/dL is a strong predictor of severe postpartum hemorrhage and DIC progression. Prepare for cryoprecipitate or fibrinogen concentrate replacement. - **Uterine Assessment Post-Delivery:** Inspect for a Couvelaire uterus (bluish, boggy discoloration). This may impair uterine contractility, requiring uterotonics (oxytocin, methylergonovine, carboprost) and intrauterine tamponade techniques. - **Neonatal Resuscitation:** Ensure a neonatal resuscitation team is present at delivery. The newborn is at high risk for acidosis, hypovolemia, and anemia. Patient Safety and Documentation - **Quantify Blood Loss:** Use a calibrated drape and weigh all sponges to accurately measure blood loss, as visual estimation is often inaccurate. - **Emotional Support:** Provide clear, calm explanations to the patient and family about the emergency and the need for immediate surgery. A perinatal loss or NICU admission is a high possibility. - **Documentation:** Record the exact time of symptom onset, initial assessment findings, notifications made, interventions performed, and the decision-to-delivery interval. ## 핵심 개념 - **Abruptio Placentae** — Premature separation of the placenta from the uterine wall before delivery, causing hemorrhage and fetal distress. - **Couvelaire Uterus** — A condition where blood extravasates into the uterine myometrium due to severe abruptio placentae, causing a rigid, board-like abdomen. - **Fetal Bradycardia** — A fetal heart rate persistently below 110 bpm, indicating severe fetal hypoxia and distress requiring immediate intervention. - **Consumption Coagulopathy** — A bleeding disorder, such as DIC, where clotting factors are depleted due to massive hemorrhage, increasing the risk of severe bleeding. - **Decidual Basalis** — The maternal portion of the placenta that interfaces with the uterine wall; its separation is the primary event in abruptio placentae. ## 같은 주제 문제 - [A 35-year-old gravida 4, para 3 client at 32 weeks gestation is admitted with acute abdomi…](https://mymerci.kr/pages/nclex_q.php?qn_id=542946) - [A 32-year-old woman at 34 weeks gestation presents to the emergency department with sudden…](https://mymerci.kr/pages/nclex_q.php?qn_id=542947) - [A 35-year-old gravida 4, para 3 client at 32 weeks gestation presents to the emergency dep…](https://mymerci.kr/pages/nclex_q.php?qn_id=542948) - [A 32-year-old woman at 34 weeks gestation presents to the emergency department with severe…](https://mymerci.kr/pages/nclex_q.php?qn_id=542950) - [A 28-year-old woman at 36 weeks gestation presents to the emergency department with sudden…](https://mymerci.kr/pages/nclex_q.php?qn_id=542951) - [A 32-year-old woman at 34 weeks gestation presents to the emergency department with sudden…](https://mymerci.kr/pages/nclex_q.php?qn_id=542952) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._