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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B, "Allow the baby to feed at least every 3 hr." The nurse should instruct the client who is breastfeeding her newborn to allow the baby to feed at least every 3 hr, which can help to establish an adequate milk supply. The client should also be instructed to feed the newborn on demand, offer both breasts at each feeding, and continue to breastfeed for as long as the baby is interested. The nurse should advise the client to expect at least six to eight wet diapers every 24 hr and monitor the newborn for signs of dehydration, such as a decrease in urine output, dry mucous membranes, or lethargy.
Correct Answer is C
Explanation
The correct answer is choice C, Ensure the newborn's eyes are closed beneath the shield. Phototherapy is a treatment used to reduce high bilirubin levels in newborns. It involves exposing the newborn's skin to special lights, which helps to break down the excess bilirubin in the blood. It is important to ensure that the newborn's eyes are closed beneath the shield to prevent damage to the eyes from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr, applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a thin layer of clothing during therapy are not indicated interventions during phototherapy.
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