A patient is admitted to the emergency department with vaginal bleeding, dizziness, and lower abdominal tenderness. Ultrasonography confirms an incomplete miscarriage with retained products of conception and a small subchorionic hematoma. The patient has mild anemia and a slightly elevated TSH. Which nursing intervention is a priority to address her current condition?

A) Administer intravenous fluids to maintain hemodynamic stability.

B) Prepare the patient for a dilation and curettage procedure.

C) Educate the patient on the use of misoprostol for medical management.

D) Adjust the patient's levothyroxine dosage to correct thyroid levels.

A 28-year-old female patient presents to the emergency department with vaginal bleeding and cramping. Ultrasonography confirms an incomplete miscarriage with retained products of conception. The patient's hemoglobin level is 10.2 g/dL. Which nursing intervention is most appropriate to address her current condition and prevent further complications?

C) Initiate misoprostol therapy to promote expulsion of retained products.

A) Administer intravenous fluids to maintain hemodynamic stability.

B) Prepare the patient for an immediate dilation and curettage.

C) Initiate misoprostol therapy to promote expulsion of retained products.

D) Monitor vital signs and reassess in 4 hours for spontaneous resolution.

A patient in the emergency department, who is undergoing medical management with misoprostol for a miscarriage, reports increased cramping and heavy bleeding. Her vital signs show a heart rate of 125 bpm and a blood pressure of 92/58 mmHg. Which nursing intervention should be prioritized to address the patient's current condition?

B) Initiate intravenous fluid therapy to support blood pressure

A) Administer oral analgesics to manage the patient's pain

B) Initiate intravenous fluid therapy to support blood pressure

C) Encourage the patient to ambulate to facilitate uterine evacuation

D) Prepare the patient for a repeat dose of misoprostol to expedite the process

A patient in the emergency department is receiving medical management with misoprostol for a miscarriage. Six hours post-administration, she presents with increased cramping and heavy bleeding, tachycardia (heart rate 125 bpm), and hypotension (blood pressure 92/58 mmHg). Her hemoglobin has decreased to 9.5 g/dL. What is the priority nursing action at this time?

B) Administer intravenous fluids as ordered

A) Continue monitoring vital signs every hour

B) Administer intravenous fluids as ordered

C) Prepare the patient for immediate surgical intervention

D) Educate the patient about the expected side effects of misoprostol

A patient is experiencing heavy uterine bleeding with signs of hemodynamic instability despite fluid resuscitation. Ultrasound reveals retained products of conception. What is the most appropriate nursing action to prioritize while preparing the patient for a D&C procedure?

C) Prepare the patient for blood transfusion to address potential anemia

A) Administer additional intravenous fluids to maintain blood pressure

B) Monitor vital signs every four hours to assess for changes

C) Prepare the patient for blood transfusion to address potential anemia

D) Educate the patient about postoperative care and recovery expectations

A nurse is caring for a patient who is experiencing heavy uterine bleeding with hemodynamic instability despite fluid resuscitation. The patient is scheduled for an urgent dilation and curettage (D&C) procedure. Which nursing intervention is most critical to perform prior to the procedure?

C) Ensure that consent for the procedure is signed and documented.

A) Encourage the patient to ambulate to the bathroom to void.

B) Administer a prescribed dose of IV antibiotics.

C) Ensure that consent for the procedure is signed and documented.

D) Position the patient in a semi-Fowler's position to improve comfort.

A 35-year-old female patient is being prepared for a dilation and curettage (D&C) procedure due to significant uterine bleeding. Her latest vital signs indicate a heart rate of 130 bpm, blood pressure of 92/58 mmHg, and oxygen saturation of 93% on room air. Her hemoglobin level is 7.8 g/dL. What is the most appropriate initial nursing intervention to address her current condition?

C) Elevate the patient's legs to improve circulation

A) Increase the flow of oxygen via nasal cannula

B) Initiate a rapid blood transfusion

C) Elevate the patient's legs to improve circulation

D) Contact the physician to request an increase in IV fluids

A patient is being prepped for a D&C procedure due to significant blood loss. Her heart rate is 130 bpm, blood pressure is 92/58 mmHg, and oxygen saturation is 93% on room air. Her hemoglobin is 7.8 g/dL, and she is lethargic. What is the priority nursing intervention to address her current clinical status?

C) Initiate intravenous fluid resuscitation to stabilize blood pressure

A) Administer a blood transfusion to address her low hemoglobin

B) Increase the oxygen flow rate to improve her oxygen saturation

C) Initiate intravenous fluid resuscitation to stabilize blood pressure

D) Monitor her vital signs every 30 minutes for any changes

A patient in the operating room is experiencing signs of hypovolemic shock following extensive uterine bleeding. Despite initial interventions, which of the following assessments should the nurse prioritize to detect early complications such as disseminated intravascular coagulation (DIC)?

C) Observe for signs of petechiae or unusual bruising

A) Monitor for changes in urine output

B) Assess for alterations in mental status

C) Observe for signs of petechiae or unusual bruising

D) Evaluate for increased respiratory rate

A nurse in the intensive care unit is assigned to care for a patient who has just undergone surgery for significant uterine bleeding and received a transfusion of O-negative blood. Which of the following assessments should the nurse prioritize to monitor for potential complications related to the patient's recent condition and treatment?

C) Assess for signs of disseminated intravascular coagulation (DIC), such as unusual bleeding and petechiae

A) Check for signs of infection, such as fever and elevated white blood cell count

B) Monitor for symptoms of heart failure, such as jugular vein distention and pulmonary crackles

C) Assess for signs of disseminated intravascular coagulation (DIC), such as unusual bleeding and petechiae

D) Evaluate for neurological changes, such as confusion and decreased level of consciousness

spontaneous abortion - Nursing Case Study

Pathophysiology

• Primary mechanism: Chromosomal abnormalities are the most common cause of spontaneous abortion, often due to errors in cell division, leading to non-viable embryos unable to develop properly.

• Secondary mechanism: Hormonal imbalances, such as insufficient progesterone, can result in inadequate uterine lining support, preventing embryo implantation or sustaining early pregnancy.

• Key complication: Uterine abnormalities, like fibroids or a septate uterus, may physically disrupt implantation or growth, increasing the risk of miscarriage.

Patient Profile

Demographics:

28-year-old female, office administrator

History:

• Key past medical history: Previous spontaneous abortion at 8 weeks gestation, mild hypothyroidism

• Current medications: Levothyroxine 75 mcg daily, prenatal vitamins

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Vaginal bleeding and abdominal cramping at 11 weeks gestation

• Key symptoms: Moderate lower abdominal pain, lightheadedness, dizziness, and passage of clots

• Vital signs: Blood pressure 100/60 mmHg, heart rate 112 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F

Section 1

Initial Assessment Findings:

Upon initial assessment in the emergency department, the patient's condition remains concerning due to the combination of her symptoms and vital signs. Her heart rate of 112 bpm and blood pressure of 100/60 mmHg suggest a compensatory response to potential blood loss, aligning with her reports of vaginal bleeding and dizziness. The physical examination reveals moderate tenderness upon palpation of the lower abdomen, consistent with her complaints of cramping. Speculum examination confirms active bleeding from the cervix and the presence of blood clots in the vaginal canal. Given her history of a previous spontaneous abortion and current presentation, the clinical team initiates further evaluation to assess the status of the pregnancy, potential complications, and the patient's overall stability.

New Diagnostic Results:

Ultrasonography is promptly conducted to evaluate the viability of the pregnancy and identify any intrauterine abnormalities. The ultrasound reveals an incomplete miscarriage, with retained products of conception visible within the uterine cavity. There is no evidence of a viable fetus, as no fetal heartbeat is detected. Additionally, the presence of a small subchorionic hematoma is noted, which may have contributed to the bleeding and increased the risk of miscarriage. Laboratory tests indicate a hemoglobin level of 10.2 g/dL, suggesting mild anemia likely due to blood loss. Her thyroid function tests show a slightly elevated TSH level, necessitating re-evaluation of her levothyroxine dosage to ensure optimal management of her hypothyroidism during this critical period.

These findings prompt the healthcare team to consider the next steps in management, focusing on stabilizing the patient, addressing the incomplete miscarriage, and preventing further complications. The clinical team discusses options such as expectant management, medical management with misoprostol, or surgical intervention via dilation and curettage, weighing the risks and benefits of each approach while considering the patient's clinical status and preferences. The patient's care plan will also include monitoring her hemodynamic stability, providing analgesia for pain management, and adjusting her thyroid medication as necessary to support her recovery and future reproductive health.

Section 2

Change in Patient Status:

Following the initial management decisions, the patient is closely monitored in the emergency department to assess her response to the chosen intervention of medical management with misoprostol. Approximately six hours after administration, the patient reports increased cramping and heavy bleeding, which are expected responses as the medication facilitates the completion of the miscarriage. However, her vital signs indicate a concerning trend: her heart rate has risen to 125 bpm and her blood pressure has dropped to 92/58 mmHg. These changes suggest the possibility of significant ongoing blood loss, prompting the healthcare team to intensify their monitoring and consider additional interventions.

A repeat hemoglobin test confirms a further decrease to 9.5 g/dL, raising concerns about her hemodynamic stability and the risk of worsening anemia. The clinical team decides to initiate intravenous fluids to support her blood pressure and considers a blood transfusion if her condition does not stabilize. Additionally, the patient's increased dizziness and weakness indicate a need for more aggressive management of her symptoms and potential complications. She is reassessed for any signs of hypovolemic shock, and her fluid balance is meticulously tracked to ensure adequate resuscitation.

The evolving clinical picture necessitates a reevaluation of the treatment plan, with the team discussing the potential need for surgical intervention should the patient's bleeding not subside. The possibility of transitioning to a surgical approach, such as dilation and curettage, is weighed against her current status and the risks associated with further delays in definitive management. The patient's preferences and her clinical condition will guide the next steps, as the team aims to stabilize her while minimizing the risk of further complications. This decision-making process underscores the importance of dynamic clinical reasoning and the ability to adapt the care plan based on real-time patient responses.

Section 3

As the patient's condition remains concerning, the healthcare team closely monitors her response to the administered intravenous fluids. Despite fluid resuscitation efforts, her heart rate remains elevated at 122 bpm, and her blood pressure has only slightly improved to 98/60 mmHg. She continues to experience heavy uterine bleeding, and her symptoms of dizziness and weakness persist. These findings suggest that the bleeding is not yet well controlled, and her hemodynamic status remains precarious.

A further assessment reveals that the patient's skin is cool and clammy, and she is becoming increasingly lethargic. Her urine output has decreased, indicating possible insufficient perfusion to her kidneys. A bedside ultrasound is performed to evaluate the status of the uterus and check for any retained products of conception that might be contributing to the ongoing hemorrhage. The ultrasound shows some retained tissue, which may be the source of continued bleeding and hemodynamic instability.

Given these developments, the clinical team discusses the urgent need for surgical intervention to prevent further deterioration. A dilation and curettage (D&C) procedure is now deemed necessary to control the bleeding and remove any remaining tissue. The patient is informed of the situation, and her consent for the procedure is obtained. Preparations are made to transfer her to the operating room, with the understanding that timely surgical management could stabilize her condition and prevent further complications such as severe anemia or hypovolemic shock. The team remains vigilant, ready to provide further supportive care as needed, illustrating the importance of adapting the treatment plan based on the patient's evolving clinical status.

Section 4

As the patient is prepped for the dilation and curettage (D&C) procedure, her clinical status continues to evolve. While being monitored in the pre-operative area, a repeat set of vital signs is taken. Her heart rate has now increased to 130 bpm, and her blood pressure has further declined to 92/58 mmHg. Additionally, her oxygen saturation has dipped to 93% on room air, prompting the healthcare team to administer supplemental oxygen via nasal cannula. The patient remains lethargic and is only intermittently responsive to verbal stimuli, suggesting her condition is worsening.

New laboratory results return, indicating that the patient's hemoglobin has dropped to 7.8 g/dL, confirming significant blood loss. Her hematocrit is also low at 24%, and her blood type has been crossmatched for possible transfusion. The low hemoglobin level, combined with her hemodynamic instability, suggests that she is at high risk for developing severe anemia and potential hypovolemic shock if the bleeding is not controlled promptly.

Recognizing the urgency, the surgical team expedites her transfer to the operating room for the D&C. Meanwhile, the anesthesiology team prepares to manage her hemodynamic status during surgery, with plans to initiate a blood transfusion if necessary. The clinical team remains acutely aware of the need to closely monitor her response to the intervention and anticipate any further complications. The focus remains on stabilizing her condition, addressing the root cause of the bleeding, and preventing any additional deterioration, emphasizing the critical role of timely and coordinated care in managing such complex cases.

Section 5

As the patient is transferred to the operating room, the surgical team notes that her condition remains critical. Despite the administration of supplemental oxygen, her oxygen saturation continues to hover around 93%, indicating a persistent need for additional respiratory support. Prior to the induction of anesthesia, the anesthesiologist observes that the patient's skin is cool and clammy, with peripheral cyanosis developing, a clear sign that her perfusion is inadequate. Her heart rate remains elevated at 132 bpm, and her blood pressure is now recorded at 88/56 mmHg, further confirming the suspicion of progressing hypovolemic shock. The clinical team promptly initiates intravenous fluid resuscitation with a crystalloid solution to address her hemodynamic instability, while preparing to administer packed red blood cells as soon as they become available.

During the surgical procedure, the obstetrics team encounters more extensive uterine bleeding than initially anticipated. They quickly proceed with the dilation and curettage, aiming to evacuate any retained products of conception contributing to the hemorrhage. Concurrently, the anesthesiology team initiates a transfusion of one unit of O-negative blood to stabilize the patient's hemoglobin levels and improve her oxygen-carrying capacity. As the transfusion progresses, the patient's vital signs show a slight improvement, with her heart rate decreasing to 120 bpm and her blood pressure stabilizing at 96/60 mmHg. Her oxygen saturation rises to 96% with the continued use of supplemental oxygen.

The surgical and anesthesiology teams remain vigilant, fully aware that while the immediate bleeding appears to be under control, the patient is not yet out of danger. They consider additional monitoring for potential complications such as disseminated intravascular coagulation (DIC) due to the severity of the blood loss and the prolonged hypotensive state. The patient's postoperative management will require close observation in the intensive care unit, where her response to the interventions will guide further treatment decisions. With the immediate crisis averted, the focus will shift towards her recovery and the prevention of further complications, underscoring the importance of coordination and diligent care in her ongoing management.