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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Swaddling the newborn with his legs extended is not the appropriate action for a newborn with neonatal abstinence syndrome (NAS). NAS occurs when a baby is born dependent on drugs, usually because the mother used opioids during pregnancy. Swaddling may provide some comfort, but extending the legs could increase discomfort and agitation.
Choice B rationale:
Scheduling larger volume feedings at less frequent intervals is not the correct approach for a newborn with NAS. These infants often have feeding difficulties and may require smaller, more frequent feedings to reduce the risk of aspiration.
Choice C rationale:
Maintaining eye contact with the newborn during feedings may not be well-tolerated by a baby with NAS. They can be irritable and easily overstimulated, and eye contact during feeding may exacerbate their agitation.
Choice D rationale:
Planning care to minimize handling of the newborn is the most appropriate action for a baby with NAS. These infants are sensitive to stimuli and can become agitated easily, so minimizing unnecessary handling helps reduce their distress.
The correct answer is D. Plan care to minimize handling of the newborn.
Here's why:
- Swaddling with legs extended: This is not recommended as it can be uncomfortable for the newborn and may exacerbate withdrawal symptoms.
- Larger volume feedings at less frequent intervals: This can be difficult for newborns with NAS due to their increased metabolic rate and may lead to overfeeding.
- Maintaining eye contact during feedings: While this is important for bonding, it can be overwhelming for newborns with NAS, who often prefer a calm environment.
Minimizing handling is a key intervention in caring for newborns with NAS. Excessive handling can trigger withdrawal symptoms and make the newborn more irritable. Instead, focus on gentle, soothing techniques like swaddling with arms tucked in, rocking, and providing a quiet, dimly lit environment.
Correct Answer is D
Explanation
Choice A rationale:
Bright, red vaginal discharge is not a typical manifestation of an ectopic pregnancy. Instead, it can be indicative of other conditions such as miscarriage or vaginal bleeding.
Choice B rationale:
A scaphoid abdomen is not a typical manifestation of an ectopic pregnancy. A scaphoid abdomen is seen in cases of diaphragmatic hernia, where the abdominal organs move into the chest cavity, leaving the abdomen with a sunken appearance.
Choice C rationale:
Elevated blood pressure is not a typical manifestation of an ectopic pregnancy. High blood pressure can be associated with conditions like preeclampsia but is not specifically linked to ectopic pregnancies.
Choice D rationale:
Sharp pelvic pain is a common manifestation of an ectopic pregnancy. As the fertilized egg implants outside the uterus, often in the fallopian tube, it can cause pain and discomfort.
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