A patient experiencing increased vaginal bleeding and cramping is admitted for observation and management of potential hypovolemic shock. Which nursing intervention is the highest priority to prevent further complications?

C) Start intravenous fluids to maintain adequate circulatory volume.

A) Administer corticosteroids to promote fetal lung maturity.

B) Initiate continuous fetal monitoring to assess fetal well-being.

C) Start intravenous fluids to maintain adequate circulatory volume.

D) Place the patient in a Trendelenburg position to improve circulation.

A 28-year-old pregnant patient at 32 weeks gestation is admitted with increased vaginal bleeding, cramping, and dizziness. Her vital signs show a heart rate of 112 bpm and blood pressure of 126/88 mmHg. Her hemoglobin is 9.0 g/dL. Which of the following nursing interventions is the priority in managing this patient?

B) Administer intravenous fluids

A) Initiate continuous fetal monitoring

B) Administer intravenous fluids

C) Start corticosteroid therapy

D) Prepare for possible emergency delivery

A pregnant patient at 32 weeks gestation is admitted with persistent vaginal bleeding and signs of maternal instability. Her vital signs include a blood pressure of 110/70 mmHg, heart rate of 118 bpm, and respiratory rate of 24 breaths per minute. Which nursing action is the priority at this time?

C) Prepare for emergency delivery

A) Administer oxygen via nasal cannula

B) Increase intravenous fluid rate

C) Prepare for emergency delivery

D) Monitor fetal heart rate continuously

A patient in the third trimester of pregnancy is experiencing significant vaginal bleeding, hypotension, tachycardia, and fetal distress. The healthcare team is considering an emergency delivery. What is the priority nursing intervention at this time?

C) Monitor fetal heart rate continuously and prepare for possible emergency C-section.

A) Administer corticosteroids to enhance fetal lung maturity.

B) Prepare the patient for an immediate blood transfusion.

C) Monitor fetal heart rate continuously and prepare for possible emergency C-section.

D) Encourage the patient to ambulate to improve circulation.

A pregnant patient experiencing hemodynamic instability and coagulopathy is being closely monitored in a critical care setting. With her blood pressure at 100/65 mmHg, heart rate at 122 bpm, and respiratory rate at 28 breaths per minute, the medical team is considering an immediate intervention. Based on this information, what is the nurse's priority action to ensure both maternal and fetal safety?

B) Prepare the patient for immediate cesarean delivery.

A) Increase the rate of intravenous fluids to stabilize blood pressure.

B) Prepare the patient for immediate cesarean delivery.

C) Administer an anticoagulant to address coagulopathy.

D) Increase the oxygen flow rate via nasal cannula.

A pregnant patient at 34 weeks gestation is experiencing hemodynamic instability and coagulopathy, with prolonged PT and aPTT. The fetal heart rate monitor shows prolonged decelerations. What is the priority nursing intervention to address both maternal and fetal concerns?

C) Prepare the patient for an immediate cesarean delivery to address fetal distress.

A) Increase the rate of IV fluids to address hypotension and improve maternal hemodynamics.

B) Administer a bolus of corticosteroids to enhance fetal lung maturity.

C) Prepare the patient for an immediate cesarean delivery to address fetal distress.

D) Apply continuous external fetal monitoring to further assess fetal status.

A patient in labor is experiencing significant blood loss with a hemoglobin level of 7.8 g/dL and has developed disseminated intravascular coagulation (DIC). The fetal heart rate monitor shows recurrent late decelerations with bradycardia. What is the priority nursing intervention to support the obstetrician's decision for an emergency cesarean delivery?

A) Administer oxygen to the mother to enhance fetal oxygenation

B) Prepare for the administration of magnesium sulfate to prevent seizures

C) Initiate a rapid infusion of packed red blood cells to address anemia

D) Position the mother supine to facilitate surgical access

A patient with suspected disseminated intravascular coagulation (DIC) is experiencing significant blood loss and fetal distress. The healthcare team has decided to proceed with an emergency cesarean delivery. Which nursing intervention is most critical in preparing the patient for surgery?

C) Ensure all required blood products are prepared and available for transfusion during surgery.

A) Start an infusion of normal saline at 75 mL/hr to maintain hydration.

B) Monitor the patient's oxygen saturation closely and administer supplemental oxygen as needed.

C) Ensure all required blood products are prepared and available for transfusion during surgery.

D) Educate the patient about the cesarean procedure to alleviate anxiety.

During the postoperative period, the nurse is monitoring a patient who underwent an emergency cesarean delivery complicated by placenta previa and DIC. Which nursing intervention is most critical to prevent further complications in this patient?

C) Monitoring vital signs and uterine tone closely for signs of hemorrhage

A) Encouraging early ambulation to prevent thromboembolism

B) Administering prescribed analgesics to manage pain effectively

C) Monitoring vital signs and uterine tone closely for signs of hemorrhage

D) Providing education on breastfeeding techniques to promote infant bonding

A nurse is caring for a postpartum patient in the recovery room following an emergency cesarean delivery complicated by placenta previa and disseminated intravascular coagulation (DIC). Despite stabilization of vital signs, the nurse notes that the patient's uterine fundus is boggy and there is continuous moderate vaginal bleeding. Which of the following actions should the nurse take first?

B) Perform fundal massage to promote uterine contraction.

A) Increase the rate of intravenous oxytocin infusion.

B) Perform fundal massage to promote uterine contraction.

C) Notify the obstetrician immediately about the bleeding.

D) Prepare the patient for possible return to the operating room.

placenta previa - Nursing Case Study

Pathophysiology

• Primary mechanism: Placenta previa occurs when the placenta implants in the lower uterine segment, covering part or all of the cervical os. This abnormal positioning can lead to impaired placental attachment and insufficient blood supply as the cervix starts to dilate in late pregnancy.

• Secondary mechanism: The lower uterine segment's inability to contract effectively around the placenta during cervical changes increases the risk of shearing forces, leading to partial placental detachment. This can cause significant maternal bleeding due to the rich vascularization of the placental tissue.

• Key complication: The compromised placental position and risk of hemorrhage can lead to maternal hypovolemia and fetal distress, necessitating careful monitoring and potential early delivery via cesarean section to prevent severe outcomes.

Patient Profile

Demographics:

32-year-old female, school teacher

History:

• Key past medical history: Previous cesarean section, mild anemia

• Current medications: Prenatal vitamins, iron supplements

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Vaginal bleeding in the second trimester

• Key symptoms: Intermittent painless vaginal bleeding, mild cramping, fatigue

• Vital signs: Blood pressure 138/92 mmHg, heart rate 98 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F

Section 1

Change in Patient Status:

Two weeks following the initial presentation, the patient returns to the hospital with increased frequency and volume of vaginal bleeding. The bleeding episodes are now accompanied by more pronounced cramping and episodes of dizziness. During the assessment, her vital signs reveal a blood pressure of 126/88 mmHg, which is lower than her previous reading, a heart rate of 112 bpm indicating potential compensatory tachycardia, and a respiratory rate of 22 breaths per minute. Her temperature remains normal. The patient appears pale and reports feeling increasingly fatigued, which may suggest worsening anemia. A repeat complete blood count shows a hemoglobin level of 9.0 g/dL, down from previous levels, indicating a further decline in her hematologic status.

The clinical team is concerned about the risk of significant blood loss and potential progression to hypovolemic shock. As a result, the decision is made to admit the patient for close monitoring and further evaluation. Continuous fetal monitoring is initiated to assess for signs of fetal distress, given the increased risk associated with placental complications. The patient is placed on bed rest to minimize further bleeding and given intravenous fluids to stabilize her hemodynamic status. The obstetric team considers the need for corticosteroid administration to accelerate fetal lung maturity in preparation for a possible preterm delivery, given the increased risk of maternal and fetal compromise. This change in the patient's status prompts a multidisciplinary discussion about the timing and method of delivery, balancing the risks of prematurity against the potential for catastrophic maternal hemorrhage.

Section 2

As the patient settles into her hospital room, the medical team continues to monitor her closely. Over the next 24 hours, her condition becomes more concerning. Despite bed rest and intravenous fluid administration, her episodes of vaginal bleeding persist, and there are signs of increasing maternal instability. Her blood pressure shows further decline, registering at 110/70 mmHg, and her heart rate remains elevated at 118 bpm, suggesting ongoing compensatory mechanisms. Her respiratory rate has increased to 24 breaths per minute, and she reports feeling more breathless and lightheaded. Her pallor is more pronounced, and she appears visibly anxious, which prompts further evaluation by the team.

A repeat complete blood count reveals a hemoglobin level that has dropped to 8.5 g/dL, indicating continued blood loss and worsening anemia. Additionally, the fetal heart rate monitor shows intermittent decelerations, raising concerns about fetal well-being. The obstetric team discusses the critical balance between prolonging the pregnancy for fetal maturity and the risks posed by maternal instability. In light of the concerning maternal signs and fetal indications, the decision is made to prepare for a possible emergency delivery.

The team initiates corticosteroid therapy to aid fetal lung maturation, anticipating an early delivery. A blood transfusion is also considered to improve maternal hemodynamics and oxygen-carrying capacity. As the situation evolves, the team remains vigilant, ready to escalate care if the patient's condition deteriorates further. This dynamic and challenging scenario requires continuous reassessment and collaboration among the medical team to ensure the best possible outcomes for both mother and child.

Section 3

New Complications:

As the medical team continues to closely monitor the patient, new complications arise that demand immediate attention. Despite the initiation of corticosteroid therapy and consideration of a blood transfusion, the patient's condition begins to show signs of further decline. Her blood pressure drops to 100/65 mmHg, indicating worsening hemodynamic instability. The heart rate remains elevated at 122 bpm, and her respiratory rate climbs to 28 breaths per minute, with the patient now experiencing increased dyspnea and tachypnea. Her oxygen saturation begins to waver, occasionally dipping to 92%, prompting the team to administer supplemental oxygen via nasal cannula to maintain adequate levels.

A newly ordered coagulation profile reveals a prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), suggesting the development of coagulopathy, which may complicate both the management of bleeding and the prospects of surgical intervention. Furthermore, the fetal heart rate monitor shows more frequent and prolonged decelerations, raising alarms about fetal distress and necessitating an urgent reevaluation of the delivery plan. The anesthesiology team is consulted to discuss potential anesthesia options, considering the patient's hemodynamic status and coagulopathy.

Given these developments, the medical team faces a critical decision-making juncture. The balance between maternal stabilization and fetal safety becomes increasingly precarious. The team considers the need for more aggressive interventions, including the potential for an immediate cesarean delivery to prevent further maternal-fetal compromise. The situation underscores the importance of interdisciplinary collaboration and swift clinical reasoning to navigate the complexities of this high-risk pregnancy, ensuring both the mother and child's safety.

Section 4

As the medical team convenes to reassess the situation, the newly available diagnostic results further illuminate the complexities at hand. The repeat hemoglobin level has dropped to 7.8 g/dL, confirming significant ongoing blood loss despite previous interventions. The fibrinogen level has also decreased to 180 mg/dL, reinforcing concerns about the development of disseminated intravascular coagulation (DIC). These findings, coupled with the earlier pattern of prolonged PT and aPTT, suggest an urgent need for correction of the coagulopathy. The team initiates the administration of fresh frozen plasma and cryoprecipitate to address the coagulation abnormalities and stabilize the patient's condition.

Simultaneously, the fetal heart rate monitor continues to display recurrent late decelerations, with sustained bradycardia periods dropping as low as 90 bpm. This alarming trend indicates fetal hypoxia and distress, which necessitates immediate action. Given the patient's hemodynamic instability and coagulopathy, the team deliberates the risks and benefits of proceeding with an expedited cesarean section versus further attempts at maternal stabilization. The anesthesiology team prepares for the potential challenges of bleeding and hemodynamic fluctuations during surgery, opting for a carefully tailored anesthetic approach that minimizes risks.

The situation demands decisive action to prevent further deterioration. The obstetrician, after consulting with the multidisciplinary team, decides to proceed with an emergency cesarean delivery to alleviate fetal distress and mitigate maternal risks. As the surgical team mobilizes, the focus shifts to ensuring efficient communication, meticulous preparation, and vigilant monitoring throughout the procedure. The goal is to achieve a successful delivery while managing the intricate balance of maternal and fetal safety, underscoring the critical nature of teamwork and clinical acumen in this high-stakes scenario.

Section 5

As the surgical team proceeds with the emergency cesarean delivery, the anesthesiology team closely monitors the patient's vital signs, noting her blood pressure has stabilized at 100/60 mmHg with a heart rate of 110 bpm, thanks to preoperative fluid resuscitation and blood product administration. Despite these improvements, her oxygen saturation fluctuates between 92-94%, indicating a need for supplemental oxygen and cautious observation for any further signs of hemodynamic instability. The team remains vigilant, mindful that the ongoing coagulopathy presents a significant risk for intraoperative hemorrhage.

During the procedure, the obstetrician successfully delivers a male infant weighing 2.8 kilograms. Although the Apgar scores are initially low at 4 and 6 at one and five minutes, respectively, the neonatal team swiftly intervenes, providing positive pressure ventilation and supplemental oxygen. The infant's heart rate improves, and color returns, signaling a positive response to resuscitation efforts. Simultaneously, the maternal side of the surgery reveals a marked increase in bleeding from the placental site, consistent with the anticipated complications of placenta previa compounded by DIC.

In response to the bleeding, the surgical team accelerates the administration of additional blood products, including packed red blood cells and more cryoprecipitate, to counteract the coagulopathy and maintain hemostasis. As the uterus is closed, the bleeding diminishes, but the team remains alert for signs of uterine atony or further bleeding. The successful delivery and stabilization of both mother and child highlight the critical importance of proactive interdisciplinary collaboration and adaptive clinical strategy in managing complex obstetric emergencies. The next steps focus on postoperative monitoring and continued assessment to prevent further complications and ensure recovery for both mother and infant.