# A nurse is caring for a laboring client who suddenly develops severe abdominal pain, cessation of contractions, and signs of shock. The fetal heart rate shows bradycardia with loss of variability. Which nursing intervention should be the immediate priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543081 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is caring for a laboring client who suddenly develops severe abdominal pain, cessation of contractions, and signs of shock. The fetal heart rate shows bradycardia with loss of variability. Which nursing intervention should be the immediate priority? ## 보기 1. Administer oxygen via face mask at 8-10 L/min 2. Insert a large-bore IV catheter and begin fluid resuscitation 3. Prepare the client for immediate cesarean delivery **✔ 정답** 4. Position the client in Trendelenburg position **정답: 3** ## 해설 Uterine rupture requires immediate cesarean delivery to control hemorrhage and deliver the fetus. Supportive measures like oxygen and IV fluids are secondary to surgical intervention. ## 심화 해설 Clinical Presentation and Pathophysiology The client’s sudden onset of severe abdominal pain, cessation of contractions, and signs of shock, combined with fetal bradycardia and loss of variability, represent a classic clinical picture of uterine rupture. This is a complete disruption of all uterine wall layers, including the serosa, as confirmed surgically in relevant cohort studies [2]. The pathophysiology involves the tearing of the myometrium, which leads to the extrusion of the fetus and placenta into the peritoneal cavity. This catastrophic event causes massive intra-abdominal hemorrhage, directly explaining the maternal hypovolemic shock. Simultaneously, the disruption of the uteroplacental unit results in acute fetal hypoxia, manifesting as profound bradycardia and the loss of fetal heart rate variability, which are terminal signs of fetal distress [2]. Priority Intervention and Rationale The immediate priority is to prepare the client for immediate cesarean delivery. In the setting of a complete uterine rupture, the maternal and fetal conditions deteriorate within minutes. The only definitive treatment to control the maternal hemorrhage and relieve the fetal asphyxia is immediate surgical intervention. The primary objective of the laparotomy is to deliver the fetus and repair or remove the damaged uterus. Research indicates that adverse neonatal outcomes in uterine rupture are profoundly time-dependent, with the decision-to-delivery interval being the most critical modifiable factor for fetal survival [2]. Every minute of delay increases the risk of irreversible hypoxic-ischemic brain injury or fetal death. While the case report highlights that this can occur even in an unscarred uterus, the cohort study confirms that a history of prior uterine surgery is the predominant risk factor, found in 86.4% of cases [2]. Regardless of the etiology, the emergency response is the same. Analysis of Alternative Options - Administer oxygen via face mask at 8-10 L/min: This is a supportive intervention to maximize maternal oxygen saturation and partial pressure, which can marginally improve oxygen delivery to the compromised fetus. However, it does not address the fundamental problem of placental separation and exsanguinating hemorrhage. It is an important but secondary action that should be performed concurrently with, not in place of, definitive surgical preparation. - Insert a large-bore IV catheter and begin fluid resuscitation: This is a critical step in managing maternal hypovolemic shock and should be initiated immediately by a second nurse or team member. Restoring intravascular volume with crystalloids and preparing for blood product transfusion are essential for maternal survival. However, fluid resuscitation alone cannot stop the internal hemorrhage; the source can only be controlled surgically. It is a resuscitative measure, not the definitive solution. - Position the client in Trendelenburg position: This position, where the head is lower than the feet, was historically used for hypotension but is no longer universally recommended as a first-line intervention for hemorrhagic shock. It can shift abdominal contents against the diaphragm, impairing ventilation, and does not effectively improve central perfusion. More importantly, like oxygen and IV fluids, it is a temporizing measure that does not treat the underlying rupture. The definitive priority is mobilizing the surgical team. The nurse’s immediate priority is to recognize the signs of uterine rupture and activate the chain of events leading to an emergency cesarean delivery, as this is the only intervention that directly addresses the cause of both maternal and fetal compromise [2].References (research sources) - [2]Factors Associated with Adverse Neonatal Outcomes in Complete Rupture of the Pregnant Uterus: A Single-Center Cohort Study.Research articleGil B, Shim S, Jang Y, Shin JS, Lee N, Kim MK, Jung YW, Seong SJ, Kim ML. (2026) · DOI: 10.3390/jpm16060327 ## 임상 시나리오 Clinical Scenario A laboring client with a history of prior cesarean delivery suddenly develops severe abdominal pain, cessation of contractions, and signs of shock. The fetal monitor shows bradycardia with loss of variability. Uterine rupture is suspected. Immediate Actions - Activate the obstetric emergency response team and call for the obstetric surgeon and anesthesiologist immediately. - Notify the neonatal resuscitation team. - Do not delay for additional diagnostic tests; clinical diagnosis is sufficient to proceed. Nursing Priorities - Prepare the client for emergency laparotomy and cesarean delivery. - Insert two large-bore IV catheters and initiate rapid fluid resuscitation with warmed crystalloid or blood products as ordered. - Administer 100% oxygen via non-rebreather mask at 10-15 L/min. - Continuously monitor maternal vital signs and fetal heart rate until transfer to the operating room. - Insert an indwelling urinary catheter to monitor output. - Prepare for possible massive transfusion protocol activation. Key Considerations - The decision-to-delivery interval is the most critical factor for neonatal survival; target less than 30 minutes. - Maternal stabilization occurs simultaneously with surgical preparation, not sequentially. - Position the client supine with a left lateral tilt to relieve aortocaval compression. - Document the time of symptom onset, notification of providers, and transfer to the operating room. ## 핵심 개념 - **Uterine rupture** — A complete disruption of all uterine wall layers leading to fetal extrusion into the peritoneal cavity and massive hemorrhage. - **Decision-to-delivery interval** — The time from the decision to perform a cesarean delivery to the actual delivery of the fetus, critical for neonatal outcomes in emergencies. - **Fetal bradycardia** — A sustained fetal heart rate below 110 bpm, indicating severe fetal distress or hypoxia. ## 같은 주제 문제 - [A nurse is caring for a laboring client at 38 weeks gestation who suddenly develops severe…](https://mymerci.kr/pages/nclex_q.php?qn_id=543077) - [A nurse is caring for a laboring client who is at 38 weeks gestation. 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