A 32-year-old pregnant patient presents with signs of hemodynamic instability and fetal distress, including a soft uterine fundus and a palpable discontinuity along the lower uterine segment. Given these findings, what is the priority nursing intervention for this patient?

B) Prepare the patient for an emergency cesarean section to address the suspected uterine rupture.

A) Administer a tocolytic to relax the uterus and alleviate discomfort.

B) Prepare the patient for an emergency cesarean section to address the suspected uterine rupture.

C) Increase the infusion rate of IV fluids to stabilize blood pressure.

D) Apply continuous external fetal monitoring to closely observe fetal heart rate patterns.

A nurse is caring for a patient who is undergoing massive transfusion protocol and preparation for an emergency cesarean section due to suspected uterine rupture. The patient's blood pressure remains low despite fluid resuscitation, and there are signs of acute kidney injury. Which of the following is the most appropriate nursing intervention to prioritize at this time?

B) Administer a vasopressor as ordered to maintain adequate blood pressure.

A) Increase the rate of IV crystalloid fluids to improve renal perfusion.

B) Administer a vasopressor as ordered to maintain adequate blood pressure.

C) Delay the transfusion to monitor for potential transfusion reactions.

D) Position the patient supine to optimize venous return and stabilize blood pressure.

A nurse in the operating room is preparing to assist with an emergency cesarean section for a patient with suspected uterine rupture and ongoing hemorrhage. Given the patient's elevated serum lactate level and prolonged coagulation times, what is the nurse's priority intervention to support optimal patient outcomes during surgery?

B) Administer fresh frozen plasma and platelets as per the transfusion protocol.

A) Increase the rate of crystalloid infusion to maintain blood pressure.

B) Administer fresh frozen plasma and platelets as per the transfusion protocol.

C) Monitor the fetal heart rate continuously to assess fetal well-being.

D) Position the patient in Trendelenburg to improve venous return.

A patient is being prepared for an emergency cesarean section due to suspected uterine rupture. Despite aggressive fluid resuscitation and transfusion protocols, the patient's blood pressure remains low, and she exhibits signs of coagulopathy. What is the most critical nursing intervention at this time to address her hemodynamic instability?

B) Prepare and administer fresh frozen plasma to correct coagulopathy.

A) Administer additional crystalloids to increase blood volume.

B) Prepare and administer fresh frozen plasma to correct coagulopathy.

C) Increase supplemental oxygen to improve oxygen saturation.

D) Monitor urine output to assess for signs of acute kidney injury.

A patient in the operating room is experiencing a change in mental status from alert and oriented to lethargic and confused, along with declining oxygen saturation levels. Which of the following interventions should the nurse prioritize to address the patient's compromised respiratory status?

C) Secure the airway through intubation to ensure adequate ventilation.

A) Administer intravenous diuretics to reduce pulmonary edema.

B) Prepare for immediate surgical intervention to control hemorrhage.

C) Secure the airway through intubation to ensure adequate ventilation.

D) Increase the rate of intravenous fluid administration to support blood pressure.

A patient in the operating room presents with lethargy, confusion, and declining oxygen saturation despite increased oxygen delivery. After intubation, her hemoglobin is found to be 6.9 g/dL, and her blood pressure is 85/55 mmHg with a heart rate of 135 bpm. Which intervention should the nurse prioritize to address the patient's hemodynamic instability?

B) Administer additional units of packed red blood cells to improve oxygen-carrying capacity.

A) Increase the rate of intravenous fluids to improve circulation.

B) Administer additional units of packed red blood cells to improve oxygen-carrying capacity.

C) Administer vasopressors to stabilize blood pressure.

D) Monitor urine output to assess kidney function.

A patient undergoing a cesarean section is suspected of developing disseminated intravascular coagulation (DIC) due to significant blood loss and lab findings of elevated D-dimer and decreased platelet count. Which nursing intervention is most appropriate to prioritize at this time?

B) Administer fresh frozen plasma and cryoprecipitate as ordered to address coagulopathy.

A) Begin administration of intravenous antibiotics to prevent infection.

B) Administer fresh frozen plasma and cryoprecipitate as ordered to address coagulopathy.

C) Position the patient in Trendelenburg to improve blood flow to vital organs.

D) Encourage early ambulation to prevent thromboembolic events.

A patient undergoing a cesarean section develops signs of disseminated intravascular coagulation (DIC). With the onset of DIC, which of the following nursing interventions is a priority to prevent further complications?

C) Monitor urine output closely and adjust fluid therapy to maintain renal perfusion

A) Administer vitamin K to promote clotting factor synthesis

B) Initiate a continuous heparin infusion to stabilize clot formation

C) Monitor urine output closely and adjust fluid therapy to maintain renal perfusion

D) Provide supplemental oxygen to maintain SpO2 above 95%

A postoperative patient with a history of DIC is being monitored in the recovery area. She presents with a urine output of 15 mL/hr, a serum creatinine level of 2.1 mg/dL, and a blood pressure of 98/65 mmHg. Which nursing intervention is most appropriate to address her current condition?

D) Contact the nephrology team to discuss potential adjustments in medication management.

A) Increase the dopamine infusion rate to enhance renal perfusion.

B) Administer a fluid bolus of normal saline to improve urine output.

C) Prepare the patient for immediate hemodialysis to address acute kidney injury.

D) Contact the nephrology team to discuss potential adjustments in medication management.

A post-operative patient with Disseminated Intravascular Coagulation (DIC) shows a slight improvement in platelet count and fibrinogen levels, but her D-dimer remains elevated. Her urine output is low, and serum creatinine is increasing. Which nursing intervention is the most appropriate to address her current condition?

C) Monitor urine output hourly and prepare for potential renal replacement therapy.

A) Increase fluid intake to improve renal perfusion and prevent acute kidney injury.

B) Administer acetaminophen to reduce fever and decrease metabolic demand.

C) Monitor urine output hourly and prepare for potential renal replacement therapy.

D) Decrease dopamine infusion to reduce the risk of further nephrotoxicity.

Ruptured uterus - Nursing Case Study

Pathophysiology

• Primary mechanism: A ruptured uterus primarily occurs due to the excessive stretching or weakening of the uterine wall, often from previous cesarean sections or uterine surgeries that create scar tissue, which lacks the tensile strength of normal uterine tissue and is prone to tearing during labor.

• Secondary mechanism: High intrauterine pressure during labor, such as from obstructed labor or the use of labor-inducing drugs like oxytocin, can exacerbate stress on the uterine wall, leading to a rupture, especially in areas of previous surgical incisions or inherent structural weakness.

• Key complication: A ruptured uterus can result in severe maternal hemorrhage and fetal distress due to compromised blood supply, necessitating immediate surgical intervention to prevent life-threatening outcomes for both the mother and the baby.

Patient Profile

Demographics:

32 years old, female, school teacher

History:

• Key past medical history: Previous cesarean section, two normal deliveries

• Current medications: Prenatal vitamins, iron supplements

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe abdominal pain and vaginal bleeding

• Key symptoms: Intense lower abdominal pain, dizziness, fainting episodes, decreased fetal movements

• Vital signs: Blood pressure 90/60 mmHg, heart rate 120 bpm, respiratory rate 24 breaths per minute, temperature 37.8°C

Section 1

As the team conducts an initial assessment, the clinical picture becomes clearer. The patient, lying in a semi-Fowler's position, appears pale and diaphoretic, with noticeable discomfort. Her abdomen is distended and tender to palpation, particularly in the lower quadrants. The fetal heart rate is monitored and reveals a pattern of late decelerations, indicating fetal distress. The patient's uterine fundus feels soft and there is a palpable discontinuity along the lower uterine segment, suggesting a possible site of rupture. Her vital signs continue to reflect hemodynamic instability, with a blood pressure now at 85/55 mmHg, heart rate persisting at 125 bpm, and respiratory rate slightly elevated at 26 breaths per minute.

Laboratory tests are expedited, revealing a hemoglobin level of 8 g/dL, indicative of significant blood loss, and a rising lactate level of 3.5 mmol/L, suggesting tissue hypoperfusion. The white blood cell count is slightly elevated at 14,000/mm³, consistent with a stress response. The clinical team initiates a massive transfusion protocol while preparing for an emergency cesarean section. Despite fluid resuscitation efforts, the patient's blood pressure remains marginal, necessitating the consideration of vasopressor support to maintain perfusion.

As preparations for surgery intensify, new complications emerge. The patient exhibits signs of acute kidney injury, evidenced by a rising serum creatinine level of 1.8 mg/dL from a baseline of 0.9 mg/dL, likely secondary to the ongoing hypovolemia and decreased renal perfusion. This development underscores the urgency of surgical intervention to control hemorrhage and stabilize the patient. The team faces the critical task of balancing rapid surgical preparation with ongoing resuscitation efforts, highlighting the need for precise coordination and clinical judgment to navigate this complex scenario successfully.

Section 2

As the surgical team swiftly prepares the patient for an emergency cesarean section, the clinical picture continues to evolve with new complications, emphasizing the critical nature of her condition. Despite fluid resuscitation and initiation of the massive transfusion protocol, the patient's hemodynamic status remains precarious. Her blood pressure shows minimal improvement, hovering around 90/60 mmHg, while her heart rate remains tachycardic at 130 bpm, indicating persistent compensatory mechanisms in response to ongoing blood loss.

A repeat set of laboratory tests reveals further concerning changes. The patient's hemoglobin has dropped to 7.5 g/dL, corroborating the suspicion of continued internal hemorrhage. Her serum lactate has risen to 4.2 mmol/L, further reflecting inadequate tissue perfusion and oxygenation. Additionally, coagulation studies demonstrate a prolonged prothrombin time (PT) of 18 seconds and an international normalized ratio (INR) of 1.7, suggesting the onset of coagulopathy, likely due to dilutional effects from transfusions and ongoing blood loss. This development necessitates the immediate administration of fresh frozen plasma and platelets to address the coagulopathy and enhance hemostasis during the impending surgery.

The patient's clinical status necessitates vigilant monitoring and swift interventions to address each emerging complication. The anesthesiology team is prepared to manage potential airway and ventilation challenges, given the patient's compromised respiratory status, as evidenced by an elevated respiratory rate and declining oxygen saturation, now at 91% on supplemental oxygen. The looming threat of multi-organ dysfunction, particularly acute kidney injury, further complicates the clinical decision-making process, as the team must judiciously balance aggressive resuscitation efforts with the need for definitive surgical intervention. As the patient is transported to the operating room, the team remains acutely aware of the delicate interplay between ongoing stabilization efforts and the critical need for surgical resolution of the uterine rupture to mitigate further deterioration.

Section 3

As the surgical team swiftly positions the patient in the operating room, they note a change in her clinical status that raises further concern. Her mental state has shifted from alert and oriented to lethargic and confused, indicating worsening cerebral perfusion. The anesthesiologist performs a rapid assessment, finding her pupils sluggishly reactive to light, which correlates with her declining oxygen saturation now at 88% despite increased oxygen delivery. These signs suggest a significant compromise in her respiratory status, possibly due to the combined effects of hypovolemic shock and developing pulmonary complications, such as pulmonary edema or aspiration.

The surgical team is acutely aware of the need to stabilize her condition before proceeding with the cesarean section. They promptly intubate the patient to secure her airway and ensure adequate ventilation, aiming to improve oxygenation and support cardiac function. Meanwhile, a new set of diagnostic results arrives, revealing a further drop in hemoglobin to 6.9 g/dL, reinforcing the urgency of surgical intervention to control hemorrhage. The team administers additional units of packed red blood cells, fresh frozen plasma, and platelets in an effort to correct the coagulopathy and stabilize her hemodynamic status.

Despite these aggressive interventions, the patient's blood pressure remains marginally stable at 85/55 mmHg, and her heart rate persists at 135 bpm, reflecting ongoing compensatory mechanisms. The team remains vigilant for signs of new complications, such as disseminated intravascular coagulation (DIC) or acute kidney injury, given her elevated creatinine levels of 1.8 mg/dL in the latest lab report. As the surgical team commences the cesarean section, they remain focused on the delicate balance between managing immediate life-threatening conditions and addressing potential long-term consequences of her critical state. The unfolding situation demands continuous reassessment and adaptation of the treatment plan to navigate the complexities of her rapidly evolving condition.

Section 4

As the surgical team proceeds with the cesarean section, they remain acutely aware of the patient's precarious condition and the potential for new complications. While the immediate concern is controlling the hemorrhage and delivering the baby safely, the anesthesiologist and surgical team are continuously monitoring for signs of disseminated intravascular coagulation (DIC), which remains a significant risk given the patient's ongoing blood loss and recent lab findings. As the surgery progresses, the patient's coagulation profile returns from the lab, showing an elevated D-dimer level of 3,500 ng/mL and a platelet count that has dropped further to 75,000/mm³, suggesting the onset of DIC.

The team quickly mobilizes to address this complication, understanding that managing DIC requires a multifaceted approach. Fresh frozen plasma and cryoprecipitate are administered to replenish clotting factors, while the underlying cause—hemorrhage from the ruptured uterus—is being actively addressed. The surgical team also prioritizes maintaining adequate tissue perfusion and oxygenation to prevent further organ damage. Despite these efforts, the patient develops petechiae on her arms and trunk, and oozing is noted from her surgical incision, indicative of a worsening coagulopathy.

Throughout the procedure, the patient's vitals are closely monitored. Her blood pressure begins to show slight improvement, stabilizing at 92/60 mmHg, while her heart rate decreases to 120 bpm, suggesting a positive response to the blood products and interventions. However, the team remains vigilant, aware that the risk of acute kidney injury persists, given the elevated creatinine and potential for decreased renal perfusion. They initiate a low-dose dopamine infusion to enhance renal blood flow, and the nephrology team is consulted for further management. As the cesarean section concludes, the team prepares for the crucial postoperative phase, knowing that the patient's journey is far from over and that continuous monitoring and adaptation of the treatment plan will be essential to address any further complications that may arise.

Section 5

As the surgical team transitions the patient to the recovery area, they continue to carefully monitor her condition, focusing on her response to the interventions for DIC and the potential development of new complications. Initial assessment findings in the postoperative unit reveal a slight improvement in her laboratory values; her platelet count has increased to 90,000/mm³, and her fibrinogen levels are beginning to normalize, indicating a partial response to the transfusions of fresh frozen plasma and cryoprecipitate. However, the patient's D-dimer remains high, at 3,200 ng/mL, suggesting ongoing fibrinolytic activity.

Vital signs post-surgery show her blood pressure stabilizing further at 98/65 mmHg, with a heart rate of 110 bpm, reflecting improved hemodynamic stability. Despite these encouraging signs, the patient's urine output remains low, at 15 mL/hr, and her serum creatinine has increased to 2.1 mg/dL, raising concerns about acute kidney injury due to previous hypotension and potential nephrotoxic exposure from necessary medications. The nephrology team decides to increase the dopamine infusion rate slightly and considers the initiation of renal replacement therapy, should the patient's renal function not improve.

The patient also continues to show signs of systemic involvement; she remains febrile with a temperature of 38.5°C, and her respiratory rate has increased to 24 breaths per minute, prompting the team to contemplate the possibility of systemic inflammatory response syndrome (SIRS) or sepsis. Blood cultures are taken to identify any infectious agents and guide antibiotic therapy. The team recognizes that the patient's condition requires a delicate balance of ongoing supportive care, vigilant monitoring, and timely interventions to address the multifaceted challenges she faces in her recovery journey. As the team plans for the next steps, they remain committed to optimizing her organ function, controlling the coagulopathy, and preventing further complications.