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 ["A","C"]
Explanation
A. Labor induction with oxytocin: The use of oxytocin for labor induction can increase the risk of postpartum hemorrhage due to uterine atony, where the uterus fails to contract effectively after delivery.
B. History of human papillomavirus: A history of human papillomavirus does not directly increase the risk of postpartum hemorrhage.
C. Vacuum-assisted delivery: Instrumental deliveries, such as those using a vacuum, are associated with an increased risk of trauma to the birth canal, which can contribute to postpartum hemorrhage.
D. Newborn weight 2.948 kg (6 lb 8 oz): A newborn weight of 2.948 kg is within the normal range and does not by itself increase the risk of postpartum hemorrhage. Larger babies (macrosomia) are more commonly associated with an increased risk.
Correct Answer is A
Explanation
The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the
abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.
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