A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has gestational hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
Placenta previa
Incompetent cervix
Prolapsed cord
Abruptio placentae
The Correct Answer is D
Choice A) Placenta previa is incorrect because this is not a likely complication for a client who has gestational hypertension and reports continuous abdominal pain and vaginal bleeding. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. It can cause painless, bright red bleeding in the third trimester, especially after intercourse or a pelvic exam. However, it does not cause abdominal pain, as the bleeding is not associated with uterine contractions or separation. Moreover, it is not related to gestational hypertension, which is a condition that causes high blood pressure during pregnancy. Therefore, this response is irrelevant and inaccurate.
Choice B) Incompetent cervix is incorrect because this is not a possible complication for a client who is at 36 weeks of gestation and has gestational hypertension and reports continuous abdominal pain and vaginal bleeding.
Incompetent cervix is a condition where the cervix is weak and unable to hold the pregnancy, leading to premature dilation and delivery. It can cause painless, watery vaginal discharge or spotting in the second trimester, followed by rupture of membranes and labor. However, it does not cause abdominal pain or heavy bleeding, as the cervix does not tear or detach from the uterus. Moreover, it is not related to gestational hypertension, which is a condition that causes high blood pressure during pregnancy. Therefore, this response is irrelevant and inaccurate.
Choice C) Prolapsed cord is incorrect because this is not a common complication for a client who has gestational hypertension and reports continuous abdominal pain and vaginal bleeding. Prolapsed cord is a condition where the umbilical cord slips through the cervix and into the vagina before the baby, compressing the cord and cutting off the blood supply and oxygen to the baby. It can cause variable or prolonged fetal heart rate decelerations, visible or palpable cord in the vagina, or fetal distress. However, it does not cause abdominal pain or bleeding, as the cord does not rupture or bleed. Moreover, it is not related to gestational hypertension, which is a condition that causes high blood pressure during pregnancy. Therefore, this response is irrelevant and inaccurate.
Choice D) Abruptio placentae is correct because this is a probable complication for a client who has gestational hypertension and reports continuous abdominal pain and vaginal bleeding. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, causing hemorrhage and hypoxia for the mother and the baby. It can cause severe, constant abdominal pain, dark red bleeding, uterine tenderness or rigidity, fetal distress or demise, or maternal shock or coagulopathy. It can be triggered by gestational hypertension, which is a condition that causes high blood pressure during pregnancy and increases the risk of placental abruption by 25%. Therefore, this response is relevant and accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a) Check the baby's diaper is incorrect because this is not a priority action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Checking the baby's diaper may be part of routine care, but it does not address the underlying cause of the grunting or improve the baby's oxygenation. Therefore, this action should be done after assessing and treating the baby's respiratory status.
Choice b) Place a pacifier in the baby's mouth is incorrect because this is not an appropriate action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Placing a pacifier in the baby's mouth may interfere with the baby's breathing and worsen the grunting, as it can obstruct the airway, increase the work of breathing, or cause aspiration. Therefore, this action should be avoided or used with caution for babies who are grunting.
Choice c) Have the mother feed the baby is incorrect because this is not a safe action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Having the mother feed the baby may increase the risk of choking or aspiration, as the baby may not be able to coordinate sucking, swallowing, and breathing. Therefore, this action should be delayed or modified until the baby's respiratory status improves.
Choice d) Assess the respiratory rate is correct because this is the most important action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Assessing the respiratory rate can help to determine the severity and cause of the respiratory distress, as well as guide further interventions such as oxygen therapy, suctioning, or medication. The normal respiratory rate for a newborn ranges from 30 to 60 breaths per minute, and it may vary with sleep or activity. A respiratory rate above 60 breaths per minute or below 30 breaths per minute indicates abnormality and requires immediate attention. Therefore, this action should be done as soon as possible for babies who are grunting.
Correct Answer is B
Explanation
Choice A) Increased urinary output: This is not a sign of sepsis in newborns. In fact, sepsis can cause reduced urinary output due to poor blood flow to the kidneys and dehydration.
Choice B) Hypothermia: This is a sign of sepsis in newborns. Sepsis can cause changes in temperature, often fever, but sometimes low temperature. Hypothermia can indicate a severe infection that affects the body's ability to regulate its temperature.
Choice C) Wakefulness: This is not a sign of sepsis in newborns. Sepsis can cause reduced activity and lethargy due to inflammation and organ dysfunction.
Choice D) Interest in feeding: This is not a sign of sepsis in newborns. Sepsis can cause reduced sucking and difficulty feeding due to poor appetite, nausea, vomiting, and abdominal distension.
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