# A 35-year-old G4P3 woman at 39 weeks gestation is in active labor when she suddenly develops severe dyspnea, cyanosis, and hypotension. Her vital signs are: BP 70/40 mmHg, HR 140 bpm, RR 32/min, O2 sat 85%. She becomes unresponsive and develops seizure-like activity. The fetal heart rate shows severe bradycardia at 60 bpm. What is the nurse's highest priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543063 > language: ko > subject: Maternal Newborn Health ## 문제 A 35-year-old G4P3 woman at 39 weeks gestation is in active labor when she suddenly develops severe dyspnea, cyanosis, and hypotension. Her vital signs are: BP 70/40 mmHg, HR 140 bpm, RR 32/min, O2 sat 85%. She becomes unresponsive and develops seizure-like activity. The fetal heart rate shows severe bradycardia at 60 bpm. What is the nurse's highest priority action? ## 보기 1. Immediately prepare for emergency cesarean section 2. Administer high-flow oxygen via non-rebreather mask 3. Establish large-bore IV access and begin fluid resuscitation 4. Call for immediate physician assistance and activate emergency response team **✔ 정답** **정답: 4** ## 해설 Activating the emergency response team is the highest priority due to the rapid progression and need for multidisciplinary care in ASP. Other actions like oxygen or IV access are important but secondary to immediate team mobilization. ## 심화 해설 Clinical Presentation and Recognition This clinical scenario depicts a classic, catastrophic presentation of an amniotic fluid embolism (AFE). The patient is a multiparous woman in active labor who experiences a sudden onset of severe dyspnea, cyanosis, and profound hypotension (BP 70/40 mmHg). This rapidly progresses to cardiovascular collapse, unresponsiveness, and seizure-like activity, with concurrent fetal bradycardia (FHR 60 bpm). As described in the literature, AFE is a "rare and life-threatening obstetric emergency" characterized by the sudden entry of fetal material into the maternal circulation, triggering "severe cardiorespiratory collapse" [1][2]. The triad of acute hypoxia, cardiovascular collapse, and coagulopathy is a hallmark, though the initial presentation is overwhelmingly cardiorespiratory in nature. Prioritization of Nursing Actions In a rapidly deteriorating maternal code situation, the nurse's priority is to activate the emergency response system and secure immediate, high-level assistance. The rationale is grounded in the complexity of AFE management, which requires a multidisciplinary team for simultaneous, life-saving interventions. - Why not option 1 (Prepare for emergency cesarean section)? While delivery is critical for fetal survival and may aid maternal resuscitation by relieving aortocaval compression, preparing the operating room is a secondary step. The immediate need is for the personnel and equipment to manage a maternal cardiac arrest. The physician team must be present to make the decision for a perimortem cesarean section. - Why not option 2 (Administer high-flow oxygen)? This is a critical intervention for the profound hypoxemia (O2 sat 85%). However, it is a single task within a larger resuscitation bundle. The nurse can apply oxygen while calling for help, but calling for help must be the first action to ensure that other simultaneous interventions (intubation, chest compressions, medication administration) can follow immediately. - Why not option 3 (Establish IV access and begin fluid resuscitation)? Fluid resuscitation is essential for the profound hypotension. However, in the setting of a suspected AFE, aggressive fluid management must be balanced against the risk of pulmonary edema and right ventricular failure. More importantly, this task requires additional hands. The nurse cannot leave the patient to start a second IV line without first summoning the team that will manage the airway, perform compressions, and prepare medications. Underlying Pathophysiology and Clinical Correlation The prioritization of calling for help is directly linked to the pathophysiology of AFE. The entry of amniotic fluid and fetal components into the maternal pulmonary vasculature causes a biphasic reaction. The initial phase involves acute pulmonary vasoconstriction, leading to right ventricular failure, severe hypoxemia, and cardiovascular collapse, exactly as seen in this patient [1]. This is often followed by left ventricular failure and a consumptive coagulopathy [2]. The case reports highlight that AFE "poses great challenges to clinical diagnosis and targeted intervention" because it is a multisystem crisis from the outset [1]. No single nurse can simultaneously manage the airway, circulation, and impending coagulopathy. The "highest priority action" is therefore to initiate the chain of survival by activating the emergency response team, which brings the necessary multidisciplinary expertise and equipment to the bedside to address the concurrent respiratory, cardiac, and hematologic emergencies.References (research sources) - [1]Amniotic fluid embolism complicated by pulmonary embolism leading to multiple organ dysfunction: case report.Case reportLiu M, Li C, Mei H, Zhang Z, Ban G, Yayuan T. (2026) · DOI: 10.3389/fmed.2026.1795316 - [2]Atypical amniotic fluid embolism presenting with isolated coagulopathy: a case report.Case reportHuang X, Zhong X, Long J, Liu X. (2026) · DOI: 10.1186/s12884-026-08733-x ## 임상 시나리오 Clinical Practice Guide: Amniotic Fluid Embolism Response In the event of a suspected amniotic fluid embolism (AFE) presenting with sudden maternal cardiovascular collapse, the nurse's immediate action is to activate the emergency response system (e.g., call a Code Blue) and summon the obstetric, anesthesia, and critical care teams. High-quality cardiopulmonary resuscitation (CPR) with manual left uterine displacement must be initiated immediately while awaiting the team's arrival. The complexity of AFE requires simultaneous, multidisciplinary interventions that cannot be performed by a single nurse, making team activation the foundational first step for all subsequent life-saving measures. ## 핵심 개념 - **Amniotic Fluid Embolism (AFE)** — A rare, life-threatening obstetric emergency where fetal material enters the maternal circulation, triggering sudden cardiorespiratory collapse and often coagulopathy. - **Emergency Response System Activation** — The immediate calling for a code blue or rapid response team to bring multidisciplinary personnel and emergency equipment to the bedside for a patient in crisis. - **Maternal Code Blue** — A cardiac arrest or peri-arrest situation in a pregnant woman requiring modifications to standard resuscitation, including left uterine displacement and preparation for perimortem cesarean delivery. - **Prioritization in Nursing** — The process of determining the most critical intervention based on patient safety and survival, often following the principle of ensuring a team is present before performing complex tasks. ## 같은 주제 문제 - [A 32-year-old gravida 2, para 1 woman at 38 weeks gestation is admitted to the labor and d…](https://mymerci.kr/pages/nclex_q.php?qn_id=543058) - [A 35-year-old gravida 3, para 2 woman at 39 weeks gestation is in active labor when she su…](https://mymerci.kr/pages/nclex_q.php?qn_id=543059) - [A nurse is caring for a laboring patient who suddenly develops severe dyspnea, hypotension…](https://mymerci.kr/pages/nclex_q.php?qn_id=543060) - [A 25-year-old primigravida at 40 weeks gestation is undergoing labor induction with oxytoc…](https://mymerci.kr/pages/nclex_q.php?qn_id=543061) - [A 32-year-old woman at 38 weeks gestation suddenly develops severe dyspnea, hypotension, a…](https://mymerci.kr/pages/nclex_q.php?qn_id=543062) - [A 32-year-old woman at 38 weeks gestation is experiencing sudden onset of severe dyspnea, …](https://mymerci.kr/pages/nclex_q.php?qn_id=543064) - [A 35-year-old woman at 37 weeks gestation is in active labor when she suddenly develops se…](https://mymerci.kr/pages/nclex_q.php?qn_id=543065) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._