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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.
Choice B rationale:
Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.
Choice C rationale:
Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.
Choice D rationale:
Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.
Correct Answer is B
Explanation
Choice A rationale:
Hct (hematocrit) of 34% is a normal finding during pregnancy. Normal ranges vary during pregnancy, but generally, a hematocrit between 33% to 45% is considered normal during the second trimester.
Choice B rationale:
BUN (blood urea nitrogen) of 25 mg/dL should be reported to the provider. BUN measures kidney function, and during pregnancy, values above 20 mg/dL may indicate possible impaired kidney function, which requires further evaluation.
Choice C rationale:
Platelets of 170,000/mm³ are within the normal range during pregnancy. The normal platelet count during pregnancy is typically between 150,000 to 400,000/mm³.
Choice D rationale:
HbA1c (glycated hemoglobin) of 6% is a good indicator of blood sugar control and is within the target range for a pregnant woman with diabetes. The target HbA1c level for pregnant women with diabetes is usually around 6% or lower.
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