A nurse is admitting a client to the birthing unit who started having contractions an hour ago. The nurse determines the client is 80% effaced and 8 cm dilated.
What condition is the client at risk for?
Incompetent cervix
Hyperemesis gravidarum
Postpartum hemorrhage
Ectopic pregnancy
The Correct Answer is C
Choice A rationale
An incompetent cervix is a condition that occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy. This condition is not directly related to the client’s current state of being 80% effaced and 8 cm dilated.
Choice B rationale
Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance. Mild cases are treated with dietary changes, rest, and antacids.
More severe cases often require a stay in the hospital so that the mother can receive fluid and nutrition through an intravenous line. This condition is not directly related to the client’s current state of being 80% effaced and 8 cm dilated.
Choice C rationale
Postpartum hemorrhage is a condition that can occur due to a variety of factors, one of which is a rapid or prolonged labor, which can result in uterine atony. Given that the client is 80% effaced and 8 cm dilated, she is in active labor and could potentially be at risk for postpartum hemorrhage.
Choice D rationale
An ectopic pregnancy is a pregnancy in which the fertilized egg implants outside the uterus. The client is already in active labor, which means the pregnancy is not ectopic.
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Correct Answer is B
Explanation
Choice A rationale
Frequent urination is a common symptom in early pregnancy due to the increased blood flow to the woman’s kidneys. This is a normal physiological change and does not require immediate attention.
Choice B rationale
Severe vomiting at 8 weeks of gestation could indicate hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy that can lead to dehydration and weight loss. This
condition requires immediate medical attention as it can have serious health implications for both the mother and the baby.
Choice C rationale
Back pain following intercourse at 36 weeks of gestation could be a sign of labor. However, it is not as urgent as severe vomiting in early pregnancy which can lead to dehydration.
Choice D rationale
Periodic tingling of the fingers at 24 weeks of gestation could be due to physiological changes in pregnancy such as fluid retention causing carpal tunnel syndrome. While this can be uncomfortable, it is not a medical emergency.
Correct Answer is D
Explanation
Choice A rationale
The weight of the newborn is not a factor in the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections caused by bacteria present in the mother’s birth canal, and this risk is not related to the newborn’s weight.
Choice B rationale
Whether the newborn was delivered via cesarean birth or vaginal birth does not affect the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections that can occur regardless of the method of delivery.
Choice C rationale
While it is important to monitor newborns for signs of infection, delaying the instillation of antibiotic ophthalmic ointment would not aid in identifying manifestations of infection. The ointment is a preventative measure and does not interfere with the observation of symptoms.
Choice D rationale
Correct answer. The instillation of antibiotic ophthalmic ointment can cause blurred vision in the newborn. Delaying the instillation of the ointment facilitates immediate bonding between the newborn and parent, as the newborn will be able to see more clearly.
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