Five minutes after a spontaneous vaginal delivery, while awaiting the expulsion of the placenta, the client suddenly grasps her chest and states, 'I can't breathe, and I feel like I'm going to die.' The client's skin rapidly becomes ashen and cyanotic. The bedside monitor reveals a sudden drop in oxygen saturation to 81% and a heart rate of 134 beats/min. Which sequence of immediate nursing actions is the highest priority?
- Administer oxygen at 10 L/min via a non-rebreather mask, establish secondary intravenous access, and prepare the crash cart for potential cardiopulmonary resuscitation.Answer
- BPerform continuous fundal massage to assist in expelling the placenta, administer an intravenous oxytocin bolus, and assess the perineum for expanding hematomas.
- CInstruct the unlicensed assistive personnel to apply a continuous pulse oximeter and obtain vital signs every 5 minutes while urgently notifying the anesthesia provider.
- DAssist the client into a supine Trendelenburg position to increase venous return and instruct the client to perform slow, deep pursed-lip breathing exercises.
Answer
The highest priority is to administer high-flow oxygen via a non-rebreather mask, establish additional intravenous access, and prepare for cardiopulmonary resuscitation.
The client is exhibiting the classic signs of Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism), which is a rare but catastrophic obstetrical emergency characterized by sudden respiratory distress, cardiovascular collapse, and profound hypoxia. According to the ABCs (Airway, Breathing, Circulation) of prioritization, the nurse must immediately administer high-flow oxygen to treat the profound hypoxia, establish additional IV access for aggressive fluid resuscitation and medication administration, and prepare for imminent cardiopulmonary arrest.
Step-by-Step Solution
Key Concept
Prioritization in obstetrical emergencies: Recognizing and managing Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism) using the ABC framework.