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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: At least you are young and can have another child is not a therapeutic response, as it minimizes the patient's grief and implies that the baby is replaceablE. The nurse should acknowledge the patient's loss and avoid making assumptions or judgments.
Choice B: I am so sorry for your loss. My heart hurts for you. Can you tell me a little bit about your baby? is a therapeutic response, as it expresses empathy and compassion and invites the patient to share their feelings and memories. The nurse should listen actively and respectfully and use the baby's name if the patient has given onE.
Choice C: There was probably something wrong and God has a way of taking care of these things is not a therapeutic response, as it rationalizes the patient's loss and imposes the nurse's religious beliefs. The nurse should respect the patient's spirituality and avoid making statements that may cause guilt or anger.
Choice D: Don't cry, be strong for your family is not a therapeutic response, as it discourages the patient from expressing their emotions and places unrealistic expectations on them. The nurse should support the patient's coping and encourage them to seek help from their family and friends.
Correct Answer is B
Explanation
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