A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn's distress?

Hypoglycemia

Phrenic nerve injury

Sepsis

Meconium aspiration syndrome

Answer and Explanation

The Correct Answer is C

Choice A reason: Hypoglycemia is a low blood sugar level that can affect newborns, especially those who are premature, small for gestational age, or have diabetic mothers. However, hypoglycemia does not explain the high FHR, the low Apgar scores, or the pale and tachypneic appearance of the newborn.

Choice B reason: Phrenic nerve injury is a rare complication of cesarean section that can cause diaphragmatic paralysis and respiratory distress in the newborn. However, phrenic nerve injury usually affects only one side of the chest, and does not cause high FHR, low Apgar scores, or pallor.

Choice C reason: Sepsis is a serious infection that can affect newborns, especially those who are exposed to prolonged rupture of membranes, as in this case. Sepsis can cause high FHR, low Apgar scores, pale and tachypneic appearance, and other signs of shock and organ failure.

Choice D reason: Meconium aspiration syndrome is a condition where the newborn inhales meconium-stained amniotic fluid into the lungs, causing respiratory distress. However, meconium aspiration syndrome usually occurs in term or post-term infants, and is associated with low FHR, not high FHR. Meconium aspiration syndrome also causes cyanosis, not pallor.

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Correct Answer is B

Explanation

Choice A reason: Polyuria is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, diabetes, or renal impairment. A client with severe preeclampsia may have oliguria, which is a urine output of less than 500 mL in 24 hours, due to the decreased renal perfusion and function.

Choice B reason: Report of headache is an expected finding in a client with severe preeclampsia, as it can indicate increased intracranial pressure, cerebral edema, or vasospasm. A client with severe preeclampsia may also have other neurological symptoms, such as blurred vision, scotoma, photophobia, or hyperreflexia.

Choice C reason: Tachycardia is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, infection, anxiety, or fetal distress. A client with severe preeclampsia may have bradycardia, which is a heart rate of less than 60 beats per minute, due to the increased vagal tone and blood pressure.

Choice D reason: Absence of clonus is not an expected finding in a client with severe preeclampsia, as it can indicate normal or decreased neuromuscular irritability. A client with severe preeclampsia may have positive clonus, which is a rhythmic jerking of the foot when the ankle is dorsiflexed, due to the increased reflex excitability and hyperactivity.

A. Continuous fetal monitoring B. Ambulate to induce labor C. Obtain a daily weight D. Assess deep tendon reflexes every hour

Correct Answer is B

Explanation

Choice A reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.

Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.

Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.

Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

Correct Answer is B

Explanation

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

Correct Answer is B

Explanation

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?