A nurse is assessing a client for Disseminated Intravascular Coagulation (DIC) following a severe placental abruption. Which of the following assessment findings would support this diagnosis? Select all that apply
Oozing of blood from a previous venipuncture site.
Development of petechiae on the client's chest and arms.
A fibrinogen level that is significantly elevated above 450 mg/dL.
Spontaneous bleeding from the gums.
A platelet count of 450,000/mm3.
Correct Answer : A,B,D
Disseminated intravascular coagulation is a secondary consumptive coagulopathy triggered by the release of tissue thromboplastin from the damaged placenta into maternal circulation. This massive activation of the clotting cascade leads to widespread microvascular thrombi, which paradoxically exhaust the available supply of platelets and coagulation factors. Consequently, the client experiences systemic hemorrhage as the body loses its ability to form stable clots, while simultaneous fibrinolysis generates fibrin degradation products that further inhibit primary hemostasis.
Rationale for correct answers
1. Oozing of blood from a venipuncture site is a classic clinical indicator of a profound coagulation deficit. In the context of an abruption, this finding suggests that the circulating levels of clotting factors have been depleted to the point where the body cannot maintain hemostasis at previous trauma sites. This "weeping" from minor puncture wounds is a hallmark sign that the client has transitioned into the hemorrhagic phase of the disorder.
2. The development of petechiae on the chest and arms reflects microvascular bleeding due to a critical lack of platelets. These small, non-blanchable red or purple spots indicate that capillary integrity is failing because there are insufficient thrombocytes to plug minute endothelial gaps. Petechiae serve as an early cutaneous warning of widespread consumption of the cellular components necessary for blood transition from a liquid to a solid state.
4. Spontaneous bleeding from the mucous membranes, such as the gums, indicates that the depletion of coagulation factors has reached a systemic level. This occurs because the fibrinogen stores are being rapidly utilized to form unnecessary microclots elsewhere in the body. Spontaneous gingival hemorrhage is a high-priority assessment finding that confirms the client is at extreme risk for internal exsanguination following the initial placental event.
Rationale for incorrect answers
3. A fibrinogen level significantly elevated above 450 mg/dL is an incorrect finding for this diagnosis, as fibrinogen is consumed, not increased. In an active case of consumption, the nurse would expect to see levels drop well below the normal pregnancy range (usually < 150 mg/dL). An elevated level would suggest a normal physiological response to pregnancy or an acute phase reactant, rather than the pathological depletion seen in this syndrome.
5. A platelet count of 450,000/mm3 is within the normal or slightly high range and contradicts a diagnosis of this nature. The consumption of thrombocytes during the widespread formation of microthrombi results in thrombocytopenia, typically with counts falling significantly below 100,000/mm3. A high or normal count indicates that the hemostatic system is still intact and the client is not currently suffering from this specific consumptive complication.
Test-taking strategy
- Identify the Core Pathology: Recognize that this condition is a consumption disorder, meaning that laboratory values for clotting components will be decreased.
- Recognize Clinical Bleeding: Look for signs of bleeding in unexpected areas, such as old IV sites (choice 1) or mucous membranes (choice 4).
- Evaluate Lab Values: Rule out choice 3 and choice 5 because they describe elevated or normal values; the correct laboratory signs include decreased fibrinogen and decreased platelets.
- Observe Skin Changes: Understand that petechiae and purpura (choice 2) are the primary dermatological manifestations of the low platelet counts associated with this emergency.
- Link to the Cause: Connect the placental abruption to the release of thromboplastin, which acts as the "match" that starts the systemic fire of microclotting and subsequent bleeding.
Take home points
- Disseminated intravascular coagulation is a life-threatening emergency characterized by both excessive clotting and paradoxical systemic bleeding.
- Laboratory markers include decreased platelets, decreased fibrinogen, prolonged prothrombin time, and elevated D-dimer levels.
- Nursing management must focus on volume replacement and the administration of blood products like fresh frozen plasma and cryoprecipitate.
- Frequent assessment for occult bleeding, such as hematuria or melena, is vital to detect internal progression of the coagulopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Abruptio placentae with fetal distress represents a critical failure of uteroplacental perfusion due to premature decidual separation. This pathological state induces rapid fetal acidemia and hypoxia as the respiratory surface area of the placenta diminishes. Immediate surgical intervention is required to prevent irreversible neurological injury or intrauterine fetal demise when compensatory mechanisms like tachycardia or peripheral vasoconstriction fail to maintain fetal cerebral oxygenation.
Rationale for correct answer
3. Immediate cesarean section is the definitive treatment for fetal distress in the presence of placental abruption. Removing the fetus from a hypoxic environment stops the progression of acidemia caused by the loss of placental gas exchange. This rapid intervention is necessary to ensure neonatal survival and to allow for direct hemostatic control of maternal retroplacental hemorrhage.
Rationale for incorrect answers
1. Expectant management is only appropriate for preterm gestations where both the mother and fetus are hemodynamically stable. Weekly ultrasounds are insufficient when active distress is present, as the condition can progress to total detachment within minutes. Delaying delivery in a distressed fetus significantly increases the risk of stillbirth and maternal coagulopathy.
2. Tocolytics are generally contraindicated in the management of moderate to severe placental abruption. Attempting to delay delivery when the fetus is already showing signs of distress allows the hematoma to expand further. This pharmacological intervention masks the uterine hypertonicity that often accompanies abruption and delays the life-saving extraction of the compromised neonate.
4. Induction of labor with oxytocin is inappropriate when fetal distress is already established. Uterine contractions further compress the already compromised spiral arteries, exacerbating intervillous hypoxia and worsening the fetal condition. A high-dose drip increases the risk of uterine rupture and rapid maternal exsanguination during a severe placental separation event.
Test-taking strategy
- Identify the Physiological Crisis: The question identifies both abruptio placentae and fetal distress, signaling a Category 3 emergency.
- Prioritize Rapid Delivery: In obstetric emergencies where the fetus is unstable, the fastest and safest delivery method (cesarean section) is the priority.
- Apply Stability Principles: Rule out expectant management (choice 1) and tocolytics (choice 2) because they are only for stable patients without distress.
- Evaluate Uterine Stress: Eliminate oxytocin induction (choice 4) as it increases uterine pressure, which is dangerous for a fetus already lacking sufficient oxygen.
- Determine Definitive Care: Recognize that once the placental-fetal unit has failed, the only way to save the fetus is to bypass the placenta through surgery.
Take home points
- Fetal distress in the context of placental abruption mandates an immediate emergency cesarean section regardless of gestational age.
- Tocolytic therapy should be avoided in placental abruption as it can mask clinical symptoms and delay necessary surgical intervention.
- Conservative management is reserved only for Grade 1 abruptions where maternal and fetal vital signs remain within normal limits.
- Prompt delivery is also a maternal life-saving measure as it allows the uterus to contract down and achieve hemostasis at the detachment site.
Correct Answer is ["A","B","D"]
Explanation
Concealed abruptio placentae is a high-acuity obstetric emergency characterized by the sequestration of blood between the decidua basalis and the uterine wall. This internal hemorrhage creates a retroplacental hematoma that increases intrauterine pressure, leading to myometrial tetany and maternal-fetal hemodynamic collapse. Because the bleeding is not visible externally, clinical assessment must focus on detecting occult expansion of the hematoma and maintaining systemic oxygenation to preserve fetal viability during the acute event.
Rationale for correct answers
1. Establishing a large-bore peripheral venous access device (18-gauge or larger) is a critical priority to facilitate rapid volume expansion. In a severe abruption, the client can lose a significant portion of their circulating volume into the retroplacental space, requiring immediate administration of crystalloids or blood products. Maintaining vascular patency ensures that the clinical team can respond to sudden hypovolemic shock without delay.
2. Monitoring the fundal height every hour provides an objective measurement of the volume of concealed blood accumulating within the uterus. As the retroplacental hematoma expands, it physically displaces the uterus upward, causing the uterine fundus to rise in the abdomen. This assessment is the most sensitive bedside indicator of progressive hemorrhage when external vaginal bleeding is absent or minimal.
4. Administering supplemental oxygen at 10 L/minute via a non-rebreather mask maximizes maternal arterial oxygen saturation. This intervention enhances the oxygen gradient across the functional portion of the placenta that remains attached. By increasing the partial pressure of oxygen in the intervillous space, the nurse helps mitigate the fetal hypoxia caused by the reduction in placental surface area.
Rationale for incorrect answers
3. Placing the client in a supine position is contraindicated because it causes the gravid uterus to compress the inferior vena cava and descending aorta. This aortocaval compression reduces venous return to the heart, leading to decreased maternal cardiac output and worsened placental perfusion. The nurse should instead use a lateral tilt or side-lying position to optimize maternal hemodynamics and fetal oxygenation.
5. Performing a digital vaginal exam is strictly contraindicated in the presence of third-trimester vaginal bleeding or suspected placental detachment until placenta previa is ruled out. Manual manipulation of the cervix can exacerbate placental separation or trigger massive hemorrhage from the lower uterine segment. Assessing for cervical ripening is not a priority during an acute abruption, as the immediate focus is on maternal-fetal stabilization and potential emergency delivery.
Test-taking strategy
- Identify the Emergency: Recognize that concealed abruption involves hidden internal bleeding that requires indirect monitoring and aggressive stabilization.
- Prioritize Circulation (C): Choice 1 addresses the need for intravenous access to manage potential or actual hypovolemic shock.
- Prioritize Oxygenation (A/B): Choice 4 addresses the immediate need to improve fetal gas exchange through maternal oxygen therapy.
- Select Condition-Specific Assessment: In a concealed bleed, the most specific physical assessment is measuring the rising fundus (choice 2).
- Eliminate Harmful Actions: Rule out the supine position (choice 3) and vaginal exams (choice 5) because they compromise perfusion or increase the risk of further bleeding.
Take home points
- Increasing fundal height and board-like abdominal rigidity are the primary clinical indicators of a concealed placental abruption.
- Large-bore intravenous access (18-gauge) is mandatory for all clients with suspected abruption to allow for rapid fluid and blood resuscitation.
- Oxygen therapy via non-rebreather mask is a standard component of intrauterine resuscitation to support fetal oxygenation during placental failure.
- Aortocaval compression must be avoided by maintaining the client in a lateral position to ensure maximal maternal-fetal blood flow.
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