A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
Incompetent cervix.
Postpartum hemorrhage.
Ectopic pregnancy.
Hyperemesis gravidarum.
The Correct Answer is B
Choice A rationale:
The incompetent cervix is not related to the client's current situation. An incompetent cervix refers to a weakened cervix that may result in premature dilation during pregnancy, leading to potential pregnancy loss or preterm birth. It is not relevant to the client's current stage of labour and cervical dilation.
Choice B rationale:
Postpartum haemorrhage is the correct condition to be concerned about in this situation. The client is 80% effaced and 8 cm dilated, which indicates she is in active labour. These signs of progress indicate that she is at risk for excessive bleeding after delivery, which is known as postpartum haemorrhage.
Choice C rationale:
An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This condition is not related to the client's current presentation, as she is already in active labour.
Choice D rationale:
Hyperemesis gravidarum is severe and persistent nausea and vomiting during pregnancy, usually during the first trimester. This condition is not relevant to the client's current situation, which involves active labour and cervical dilation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not advise the client to "Move your toddler to his new bed 2 months before the baby comes home.”. This can disrupt the toddler's routine and create unnecessary stress during a significant transition in their life.
Choice B rationale:
It is not appropriate to "Avoid bringing your toddler to prenatal visits.”. Involving the toddler in prenatal visits can help them adjust to the idea of a new sibling and reduce potential jealousy or feelings of being excluded.
Choice C rationale:
The correct answer is to "Let your toddler see you carrying the baby into the home for the first time.”. This approach allows the toddler to witness the arrival of the new sibling and can help them feel involved and excited about the new addition to the family.
Choice D rationale:
"Require scheduled interactions between the toddler and the baby”. is not the best response. While it's essential to facilitate interactions between the toddler and the baby, forcing scheduled interactions may cause stress and resistance, especially if the toddler is not ready for such encounters.
Correct Answer is B
Explanation
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
Choice C rationale:
A haemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While haemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
Choice D rationale:
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.
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