A nurse is caring for a client who is in active labor and reports sudden, severe lower abdominal pain. The nurse observes a drop in the client's blood pressure and notes cool skin and pallor. The fetal heart rate tracing shows prolonged bradycardia. Which of the following complications should the nurse suspect?
Amniotic fluid embolism
Umbilical cord prolapse
Uterine rupture
Placenta previa
The Correct Answer is C
Uterine rupture. The sudden, severe lower abdominal pain, drop in blood pressure, and signs of shock such as cool skin and pallor all point to a potential intra-abdominal hemorrhage most likely due to Uterine rupture. Additionally, the prolonged bradycardia on the fetal heart rate tracing indicates that the baby may be experiencing fetal distress due to a compromised blood supply. Amniotic fluid embolism triggers an allergic reaction, causing a sudden onset of respiratory distress, hypotension, and cardiac arrest. Option D, placenta previa, occurs when the placenta implants in the lower uterine segment, partially or completely covering the cervical os. This can lead to painless vaginal bleeding but typically does not present with sudden, severe abdominal pain or signs of shock.
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Related Questions
Correct Answer is C
Explanation
A. Discomfort in the lower back (sacral area) is common during labor, particularly during contractions. This is not an unusual finding that would require immediate reassessment.
B. Contractions lasting between 45 to 60 seconds are typical during the active phase of labor. This duration of contractions is expected as labor progresses, and does not require immediate reassessment.
C. This sensation can indicate that the fetus has descended into the birth canal and may be a sign that the client is entering the second stage of labor, or is close to delivery. This requires immediate reassessment by the nurse to check for full cervical dilation and fetal descent.
D. Emotional excitement and changes in skin temperature are typical responses during labor due to the physiological and emotional aspects of childbirth. This does not indicate the need for immediate reassessment.
Correct Answer is B
Explanation
The correct answer is choice B. Facial petechiae are a clinical finding that can occur in newborns who had a nuchal cord during delivery. The nuchal cord occurs when the umbilical cord becomes wrapped around the fetal neck one or more times. Erythema toxicum is a common, benign rash that appears as small, firm, yellow, or white papules surrounded by a red halo. Periauricular papillomas and telangiectatic nevi are not associated with the nuchal cord.
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