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 D

Explanation

Choice A rationale:

The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.

Choice B rationale:

Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.

Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.

Choice C rationale:

Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.

A. Newborn weight 2.948 kg (6 lb 8 oz). B. History of uterine atony. C. Labor induction with oxytocin. D. History of human papillomavirus.

Correct Answer is ["B","C"]

Explanation

Choice A rationale:

Newborn weight of 2.948 kg (6 lb 8 oz) does not place the client at risk for postpartum hemorrhage. Newborn weight is not directly related to the risk of postpartum hemorrhage in the mother.

Choice B rationale:

History of uterine atony places the client at risk for postpartum hemorrhage. Uterine atony is the most common cause of postpartum hemorrhage and refers to the inability of the uterus to contract effectively after childbirth, leading to excessive bleeding.

Choice C rationale:

Labor induction with oxytocin places the client at risk for postpartum hemorrhage. Oxytocin is commonly used to induce labor or augment contractions, but it can cause uterine hyperstimulation, leading to increased risk of postpartum hemorrhage.

Choice D rationale:

History of human papillomavirus (HPV) does not place the client at risk for postpartum hemorrhage. HPV is a sexually transmitted infection and does not have a direct connection to the risk of postpartum hemorrhage.

Choice E rationale:

Vacuum-assisted delivery places the client at risk for postpartum hemorrhage. Vacuum assisted delivery involves using a vacuum device to assist in the baby's delivery, and it can cause trauma to the birth canal, leading to increased bleeding risk in the mother.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum haemorrhage?(Select all that apply.)

Correct Answer is ["B","C"]

Explanation

A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse?

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take?

A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

A nurse is caring for a client who is experiencing uterine atony immediately following delivery. The client fails to respond to oxytocin administration. The nurse should anticipate the use of which of the following medications?