A nurse is caring for a client on the labor and delivery unit.
Complete the following sentence by using the lists of options.
The client is at highest risk for developing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Goodell’s sign:
Goodell's sign refers to the softening of the cervix that occurs early in pregnancy, typically around 4–6 weeks. It is a probable sign of pregnancy due to increased vascularity and hormonal changes. However, it does not describe the movement of the fetus or the sensation felt by the provider when pressure is applied to the cervix.
B) Lightening:
Lightening refers to the sensation of the fetus dropping or descending into the pelvic cavity, which typically happens in the later stages of pregnancy (around 36 weeks or later). It is not related to the fetal movement felt by the provider through upward pressure on the cervix, but rather to the physical repositioning of the fetus as it prepares for labor.
C) Ballottement:
Ballottement is the correct term for the movement of the fetus that can be felt by the provider when upward pressure is applied to the cervix. This technique involves a gentle tapping or pushing on the cervix, causing the fetus to rise and then "bounce" back. This is a probable sign of pregnancy, typically noticeable between 16 and 18 weeks gestation.
D) Chadwick's sign:
Chadwick’s sign refers to the bluish discoloration of the cervix, vagina, and vulva due to increased blood flow and is often an early sign of pregnancy. It does not relate to the movement of the fetus felt by the provider, but rather to changes in the color of the genital tissues.
Correct Answer is A
Explanation
A) G5 T1 P2 A1 L2:
G (Gravida): Gravida refers to the total number of pregnancies, including the current pregnancy. In this case, the woman is currently pregnant and has had 4 previous pregnancies (one miscarriage at 10 weeks, one at 22 weeks, and two live births). Therefore, her Gravida (G) is 5.
T (Term births): Term births are those that occur at or after 37 weeks of gestation. The woman delivered an 18-month-old daughter who was born 2 days after her due date, which is a term birth. Thus, her Term (T) is 1.
P (Preterm births): Preterm births occur between 20 and 36 weeks of gestation. The woman had a son born at 35 weeks, which is classified as a preterm birth. Therefore, the Preterm (P) is 2.
A (Abortions or miscarriages): Abortions refer to pregnancies that ended before 20 weeks of gestation. The woman experienced two miscarriages, one at 10 weeks and one at 22 weeks. Thus, the Abortions (A) is 1.
L (Living children): Living children are those who are currently alive. The woman has a 3-year-old son and an 18-month-old daughter, so the Living (L) is 2.
Thus, the correct GTPAL classification is G5 T1 P2 A1 L2.
B) G5 T2 P2 A1 L2:
This is incorrect because the woman had only one term birth (not two). She delivered her daughter at term, but the son was preterm (born at 35 weeks). Therefore, her Term (T) should be 1, not 2.
C) G4 T1 P2 A2 L2:
This is incorrect because the woman is currently pregnant, so her Gravida (G) is 5, not 4. Additionally, the woman had 1 abortion, not 2.
D) G4 T1 P1 A2 L2:
This is also incorrect because the woman is currently pregnant, so her Gravida (G) is 5, not 4. Furthermore, the woman had 2 preterm births, not 1.
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