A 22-year-old woman presents to the emergency department with abdominal pain and vaginal bleeding. Her blood pressure is 90/58 mm Hg, her pulse is 120 beats/minute, and she complains of dizziness
Which action by the nurse takes priority?
A.
Assess the woman for sexually transmitted infections.
B.
Collect a urine sample for pregnancy testing.
C.
Obtain informed consent for a salpingectomy.
D.
Start two large-bore IVs for fluid replacement.
ANS: D
This patient has both signs (hypotension, tachycardia) and symptoms (complaints of dizziness) of acute volume loss. The nurse should consider a ruptured ectopic pregnancy as a possible problem in this patient and assess her for other manifestations and risk factors. However, the priority is starting large-bore IV lines for fluid resuscitation. The nurse may need to obtain informed consent for an operative procedure once a definitive diagnosis is made.
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