A nurse is caring for a client who is in pre-term labor.

Which of the following maternal complications is most likely to occur due to prolonged bed rest?

Thromboembolism

Placental abruption

Uterine atony

Infection

Answer and Explanation

The Correct Answer is A

Thromboembolism.

Prolonged bed rest increases the risk of venous stasis and blood clot formation in the lower extremities, which can lead to pulmonary embolism if the clot dislodges and travels to the lungs.

This is a life-threatening complication that requires immediate treatment.

Choice B. Placental abruption is wrong because it is not caused by bed rest, but by trauma, hypertension, cocaine use, or other factors that can cause the placenta to separate from the uterine wall.

Choice C. Uterine atony is wrong because it is not caused by bed rest, but by overdistension of the uterus, prolonged labor, infection, or other factors that can impair the contraction of the uterine muscles after delivery.

Choice D. Infection is wrong because it is not caused by bed rest, but by poor hygiene, invasive procedures, or other factors that can introduce microorganisms into the reproductive tract.

Normal ranges for maternal heart rate are 60-100 beats per minute and blood pressure are 110-140/60-90 mm Hg.

Normal range for fetal heart rate is 110-160 beats per minute.

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Correct Answer is A

Explanation

Assess fetal heart rate and activity.

The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.

Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.

Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.

Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.

A. Referral to community services for support B. Encouragement to smoke in moderation C. Instructions for heavy lifting and strenuous exercise D. Recommendation to avoid kangaroo care

Correct Answer is A

Explanation

A. Referral to community services for support.

Referral to community services for support is an important part of the discharge plan for a client in preterm labor.Community services can provide education, counseling, home visits, and other resources to help the client cope with preterm labor and prevent complications.

B. Encouragement to smoke in moderation.Statement is wrong because smoking is harmful for the unborn baby and can increase the risk of preterm labor.Smoking should be avoided completely during pregnancy and the client should be advised to quit or seek help to quit.

C. Instructions for heavy lifting and strenuous exercise.Statement is wrong because heavy lifting and strenuous exercise can trigger contractions and worsen preterm labor.The client should be instructed to rest as much as possible and avoid activities that may cause uterine irritation or bleeding.

D. Recommendation to avoid kangaroo care.Statement is wrong because kangaroo care, or skin-to-skin contact with the baby, is beneficial for both the mother and the baby after birth.Kangaroo care can help regulate the baby’s temperature, heart rate, breathing, and blood sugar levels, as well as promote bonding, breastfeeding, and infection prevention.The client should be encouraged to practice kangaroo care as soon as possible after delivery.

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A nurse is caring for a client who is in pre-term labor. Which of the following maternal complications is most likely to occur due to prolonged bed rest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who is in pre-term labor.

Which of the following maternal complications is most likely to occur due to prolonged bed rest?