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A nurse is caring for a client on the labor and delivery unit.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

as evidenced by the client's.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Uterine rupture: A client in active labor with a history of prior vaginal birth is at risk for uterine rupture, particularly when experiencing intense contractions and increasing pelvic pressure. While previous vaginal delivery lowers the risk compared to a history of cesarean section, prolonged or strong contractions can still contribute to uterine rupture, especially if there is an undiagnosed uterine scar or excessive uterine stress.

Increasing pelvic pressure: The client reports increasing pelvic pressure despite receiving an epidural, which can be a sign of impending uterine rupture. While pelvic pressure is expected during labor, a sudden or intense sensation, particularly in the setting of strong contractions and rapid cervical dilation, warrants close monitoring.


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Related Questions

Correct Answer is B

Explanation

A) Category I:
Category I fetal heart rate patterns are considered normal and are characterized by a baseline fetal heart rate of 110–160 beats per minute, moderate variability, and the presence of accelerations. The pattern also lacks concerning decelerations. While this client’s fetal heart rate is within the normal baseline range (150 bpm), the presence of occasional variable decelerations indicates that the fetal heart rate pattern does not meet the criteria for Category I.

B) Category II:
Category II includes all fetal heart rate patterns that are not classified as Category I or III. This category represents indeterminate or concerning patterns, which require ongoing assessment and interventions. In this case, the fetal heart rate pattern includes a baseline within the normal range, moderate variability, accelerations, but also occasional variable decelerations. Variable decelerations, particularly when they occur intermittently, are often considered non-reassuring but not immediately concerning if they resolve quickly, placing the pattern in Category II.

C) Uncategorized:
"Uncategorized" refers to situations where the fetal heart rate pattern cannot be classified due to insufficient information or an unclear pattern. This is not applicable here because the nurse has identified sufficient data to classify the pattern.

D) Category III:
Category III patterns are considered abnormal and require prompt intervention. These patterns are characterized by persistent decelerations, such as late decelerations, bradycardia, or variable decelerations that do not resolve with interventions. Since the variable decelerations in this case are occasional and not persistent or severe, this pattern does not meet the criteria for Category III.

Correct Answer is D

Explanation

A) Palmer grasp reflex:
The palmer grasp reflex is a primitive reflex in which a newborn will grasp an object placed in their hand. While this reflex is present at birth, it typically disappears by 5-6 months of age, not by 3-4 months. The Moro reflex, which is more related to startle and sudden movements, is the correct answer in this case.

B) Babinski reflex:
The Babinski reflex, in which the toes fan out when the sole of the foot is stroked, is present at birth but typically disappears by 12 months. This reflex is an indicator of neurological development, and its presence beyond the first year could suggest neurological concerns, but it is not the reflex in question here.

C) Rooting reflex:
The rooting reflex occurs when the newborn turns their head and opens their mouth in response to cheek stimulation, typically to find the nipple for breastfeeding. This reflex is present at birth and usually disappears by 3-4 months, which is similar to the timing mentioned in the question.

D) Moro reflex:
The Moro reflex is a startle reflex in which the infant spreads their arms and then pulls them back in when they feel a sudden loss of support or a loud noise. This reflex is present at birth and typically disappears by 3-4 months of age. It is considered a classic primitive reflex that fades as the infant's nervous system matures.

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