A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks of gestation and reports continuous abdominal pain and dark red vaginal bleedinG. The tocodynamometer shows low amplitude high frequency uterine activity. The nurse should identify that the client is likely experiencing which of the following complications? (Select onE.:
Prolapsed cord
Premature rupture of membranes
Abruptio placentae
Placenta previa
The Correct Answer is C
Choice A: Prolapsed cord is not a likely complication, as it is characterized by a sudden onset of severe variable decelerations of the fetal heart rate and a visible or palpable cord in the vaginA. The nurse should identify a prolapsed cord as a medical emergency and perform immediate interventions to relieve the cord compression and deliver the fetus.
Choice B: Premature rupture of membranes is not a likely complication, as it is characterized by a gush or a trickle of clear or yellowish fluid from the vagina and a positive nitrazine or fern test. The nurse should identify premature rupture of membranes as a risk factor for infection and monitor the fetal heart rate and the maternal temperaturE.
Choice C: Abruptio placentae is a likely complication, as it is characterized by continuous abdominal pain and dark red vaginal bleeding and a board-like abdomen. The nurse should identify abruptio placentae as a life-threatening condition that involves the premature separation of the placenta from the uterine wall and can cause fetal distress and maternal hemorrhagE.
Choice D: Placenta previa is not a likely complication, as it is characterized by painless bright red vaginal bleeding and a soft and relaxed uterus. The nurse should identify placenta previa as a condition that involves the abnormal implantation of the placenta near or over the cervical os and can cause fetal hypoxia and maternal hemorrhagE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Explaining to the client what is happening over the next few minutes in detail and asking for teach back from the spouse is not the first action, as it may delay the urgent intervention and increase the anxiety of the client and the spousE. The nurse should provide brief and clear information and reassurance after taking the first action.
Choice B: Placing the client in a knee-chest or Trendelenburg position and raising the presenting part off the cord with your hand is the first and most important action, as it relieves the pressure on the cord and prevents cord compression and fetal hypoxiA. The nurse should maintain this position until the delivery.
Choice C: Covering the cord with a sterile, moist saline dressing is a secondary action, as it prevents the cord from drying and reduces the risk of infection. The nurse should perform this action after taking the first action.
Choice D: Preparing the client for an emergency cesarean birth is a tertiary action, as it is the definitive treatment for cord prolapse and ensures the safety of the mother and the fetus. The nurse should perform this action after taking the first and second actions.
Correct Answer is B
Explanation
Choice A: Thromboembolic events are not prevented by methylergonovinE. Thromboembolic events are blood clots that can form in the veins or arteries and cause serious complications such as pulmonary embolism or strokE. Methylergonovine is a uterotonic agent that stimulates the contraction of the uterus and can actually increase the risk of thromboembolic events by causing vasoconstriction and hypertension.
Choice B: Postpartum hemorrhage is prevented by methylergonovinE. Postpartum hemorrhage is excessive bleeding after delivery that can result from uterine atony, retained placenta, or lacerations. Methylergonovine is a uterotonic agent that stimulates the contraction of the uterus and helps control the bleeding by compressing the blood vessels and expelling any placental fragments.
Choice C: Postpartum infection is not prevented by methylergonovinE. Postpartum infection is a bacterial infection that can affect the uterus, the vagina, the bladder, or the breast after delivery. Methylergonovine is a uterotonic agent that has no antibacterial activity and can actually increase the risk of infection by causing fever and chills.
Choice D: Hypertension is not prevented by methylergonovinE. Hypertension is high blood pressure that can cause complications such as preeclampsia, eclampsia, or strokE. Methylergonovine is a uterotonic agent that can actually cause or worsen hypertension by stimulating the alpha-adrenergic receptors and causing vasoconstriction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
