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 A
Explanation
Correct Answer is C
Explanation
Choice A: Polyhydramnios is not a cause of variable decelerations. Polyhydramnios is a condition where there is an excessive amount of amniotic fluid, which can cause complications such as preterm labor, placental abruption, and cord prolapsE. Polyhydramnios can cause late decelerations, which are a sign of uteroplacental insufficiency and fetal hypoxiA.
Choice B: Fetal head compression is not a cause of variable decelerations. Fetal head compression is a normal physiological response to the uterine contractions and the descent of the fetal head into the pelvis. Fetal head compression can cause early decelerations, which are a benign and reassuring pattern that mirror the contractions.
Choice C: Umbilical cord compression is a cause of variable decelerations. Umbilical cord compression is a condition where the blood flow through the umbilical cord is reduced or interrupted, which can result from cord prolapse, cord knots, or cord wrapping around the fetal neck or limbs. Umbilical cord compression can cause variable decelerations, which are abrupt and irregular decreases in the FHR that vary in shape, duration, and timinG.
Choice D: Maternal fever is not a cause of variable decelerations. Maternal fever is a condition where the mother's body temperature is elevated, which can indicate an infection or inflammation. Maternal fever can cause tachycardia, which is a high FHR above the normal range of 110 to 160 beats/min.
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