A nurse is caring for a client who is in active labour 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.

Uterine rupture.

Umbilical cord prolapse.

Placenta previa.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Amniotic fluid embolism is a rare but serious complication during labor or immediately after delivery, where amniotic fluid, fetal cells, hair, or other debris enter the mother's bloodstream and cause a severe reaction. While it may present with sudden and severe symptoms, such as hypotension and respiratory distress, it does not typically cause uterine rupture.

Choice B rationale:

Uterine rupture is a life-threatening emergency that can occur during labor, especially in women with previous uterine surgeries or trauma. The sudden, severe lower abdominal pain, drop in blood pressure, cool skin, and pallor could indicate internal bleeding and shock, which are consistent with uterine rupture. Prolonged bradycardia on the fetal heart rate tracing suggests fetal distress due to compromised blood flow.

Choice C rationale:

Umbilical cord prolapse is another obstetric emergency that occurs when the umbilical cord slips through the cervix and gets compressed during labor, leading to fetal distress. It may cause variable decelerations in fetal heart rate, but it does not explain the maternal symptoms described in the scenario, such as the sudden, severe lower abdominal pain, hypotension, cool skin, and pallor.

Choice D rationale:

Placenta previa is a condition where the placenta covers part or all of the cervix, and it can lead to painless vaginal bleeding. While it can cause fetal distress, it does not explain the maternal symptoms like the sudden, severe lower abdominal pain, hypotension, cool skin, and pallor. Prolonged bradycardia on the fetal heart rate tracing is more suggestive of uterine rupture.

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Correct Answer is C

Explanation

The correct answer is c. Cleanse the newborn immediately after delivery. This is because cleansing the newborn can reduce the risk of HIV transmission through exposure to maternal blood or fluids. The other options are not appropriate for the following reasons:

a. Administer IV antibiotics to the newborn. This is not necessary unless the newborn has signs of infection or sepsis. Antibiotics do not prevent or treat HIV infection.
b. Encourage the mother to breastfeed her newborn. This is contraindicated for mothers with HIV, as breastfeeding can transmit the virus to the infant. Mothers with HIV should avoid breastfeeding and use formula or donor milk instead.
d. Initiate contact precautions for the newborn. This is not required for newborns exposed to HIV, as HIV is not transmitted by casual contact. Standard precautions are sufficient to prevent the spread of HIV and other bloodborne pathogens.

A. Request that the provider insert an intrauterine pressure catheter. B. Exert continuous upward pressure on the presenting part. C. Initiate oxytocin via continuous IV infusion. D. Place the client in the left-lateral position.

Correct Answer is B

Explanation

Choice A rationale:

Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.

Choice B rationale:

Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This manoeuvre is called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.

Choice C rationale:

Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.

Choice D rationale:

Placing the client in the left-lateral position is not the best immediate action for cord palpation. While the left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.

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Naxlex Comprehensive Predictor Exams

A nurse in the labour and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

Correct Answer is C

Explanation

A nurse is admitting a client who is at 38 weeks of gestation following a spontaneous rupture of membranes. The nurse performs a vaginal examination and palpates the umbilical cord. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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