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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Obtaining a specimen for a Kleihauer-Betke test is not the immediate action to take when a patient is experiencing a large amount of vaginal bleeding due to uterine atony.
Choice B rationale
Misoprostol is a medication that can be used to treat uterine atony. It helps to contract the uterus and reduce bleeding.
Choice C rationale
Administering betamethasone IM is not the appropriate action. Betamethasone is a steroid medication often used to mature the lungs of a fetus at risk of premature birth, not to treat uterine atony.
Choice D rationale
Avoiding sterile vaginal examinations is not the immediate action to take when a patient is experiencing a large amount of vaginal bleeding due to uterine atony.
Correct Answer is D
Explanation
Choice A rationale
A heart rate of 89/min is within the normal range for adults, and would not typically be a cause for concern.
Choice B rationale
A blood pressure of 120/70 mm Hg is considered normal for adults.
Choice C rationale
Moderate lochia serosa is a normal part of the postpartum period.
Choice D rationale
This is the correct answer. Cool, clammy skin can be a sign of postpartum hemorrhage, a serious condition that requires immediate medical attention.
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