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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse in the emergency department is evaluating a pregnant client at 37 weeks of gestation who sustained blunt abdominal trauma from a fall. The nurse suspects abruptio placentae and is monitoring for early signs of hypovolemic shock. Which of the following clinical findings indicate the client is in the early (compensatory) stage of shock? Select all that apply.

  1. Maternal heart rate of 124 beats/minuteAnswer
  2. Client reports feeling unusually restless and anxiousAnswer
  3. C
    Maternal blood pressure of 82/48 mm Hg
  4. Maternal respiratory rate of 26 breaths/minuteAnswer
  5. E
    Electronic fetal monitoring displaying recurrent early decelerations
  6. F
    Maternal skin that is warm, dry, and flushed

Answer

The clinical findings that indicate the early (compensatory) stage of shock are a maternal heart rate of 124 beats/minute, the client feeling unusually restless and anxious, and a maternal respiratory rate of 26 breaths/minute.
During the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain cardiac output and tissue perfusion. This neurohormonal response causes an increase in heart rate (tachycardia) and respiratory rate (tachypnea). Decreased cerebral perfusion combined with sympathetic stimulation also leads to early neurological changes, presenting as anxiety, apprehension, or restlessness.

Step-by-Step Solution

1
Identify the primary complication being monitored.
The nurse is monitoring for early (compensatory) hypovolemic shock secondary to abruptio placentae.
Understanding the timeline of shock helps differentiate early from late signs.
2
Recall the physiological manifestations of the early compensatory stage of shock.
Early signs include sympathetic nervous system activation: tachycardia, tachypnea, anxiety, restlessness, and cool/clammy skin. Blood pressure remains relatively normal.
The body is compensating for blood loss to maintain perfusion to vital organs.
3
Evaluate each option against the expected findings for early shock.
Tachycardia, tachypnea, and restlessness match early shock. Hypotension is a late sign. Early decelerations are unrelated to shock. Warm skin contradicts the expected peripheral vasoconstriction.
Systematic elimination ensures the correct signs of early shock are identified.

Key Concept

Recognition of early physiological indicators of hypovolemic shock in an obstetric client
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Topics

Ante/Intra/Postpartum and Newborn Care

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