The nurse is caring for a patient experiencing precipitous Labor. What complication will the nurse monitor this patient for?

Maternal hypertension

Postpartum haemorrhage

Newborn hyperglycaemia

Premature rupture of membranes

Answer and Explanation

The Correct Answer is B

Choice A reason: Maternal hypertension, or high blood pressure, is not directly associated with precipitous Labor. While hypertension can be a concern during pregnancy, it is not a primary complication resulting from a rapid Labor process. The nurse's focus would be on other specific complications that arise from precipitous Labor.

Choice B reason: Postpartum haemorrhage is a significant risk for patients experiencing precipitous Labor. Rapid Labor can lead to excessive uterine contractions, which might cause trauma to the birth canal, including lacerations and uterine atony (failure of the uterus to contract properly after delivery). These conditions can lead to significant blood loss and necessitate close monitoring and intervention to manage and mitigate the haemorrhage.

Choice C reason: Newborn hyperglycaemia, which refers to elevated blood sugar levels in the newborn, is not related to the process of precipitous Labor. This condition is more commonly associated with maternal diabetes and is not a typical complication the nurse would monitor for in this scenario.

Choice D reason: Premature rupture of membranes, which refers to the breaking of the amniotic sac before Labor begins, is not a complication resulting from precipitous Labor. It is a condition that can precede Labor but is not caused by the rapid progression of Labor. The nurse would be more concerned with managing complications directly related to the rapid Labor and delivery process.

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Correct Answer is B

Explanation

Choice A reason: Preparing to hang hypotonic fluids is not the immediate priority in this situation. While hydration is important for managing sickle cell anaemia, the infant's respiratory distress and low oxygen saturation levels indicate that addressing oxygenation should be the first step. Hypotonic fluids may be considered after stabilizing the patient's breathing and oxygen levels.

Choice B reason: Administering oxygen via nasal cannula is the priority intervention given the infant's symptoms. The infant has increased work of breathing, a fever, coarse crackles upon auscultation, and low oxygen saturation (89%). Providing supplemental oxygen is crucial to improve oxygenation and alleviate respiratory distress. Prompt intervention is necessary to prevent further complications and stabilize the patient's condition.

Choice C reason: Providing patient education on acute chest syndrome is important, but it is not the immediate priority in this emergency situation. Education can be given once the infant's acute symptoms are managed and stabilized. The focus should be on addressing the critical needs first, such as oxygenation and respiratory support.

Choice D reason: Giving a dose of morphine sulphate may help manage pain, but it is not the first priority in this scenario. The infant's respiratory status and oxygenation levels are more critical and require immediate attention. Pain management can be addressed after ensuring the infant's breathing and oxygen levels are stabilized.

A. Observing for mental confusion or hallucinations. B. Assessing motor function. C. Monitoring for a decrease in spasticity. D. Performing a follow-up MRI.

Correct Answer is C

Explanation

Choice A reason: Observing for mental confusion or hallucinations is important, but it is not the priority action following myelography. While these symptoms can occur due to complications, they are less common than changes in muscle tone or motor function.

Choice B reason: Assessing motor function is crucial, but the priority is specifically monitoring for changes in muscle tone, such as a decrease in spasticity. Myelography can affect the spinal cord and nerve roots, potentially leading to changes in muscle tone and motor function.

Choice C reason: Monitoring for a decrease in spasticity is the priority nursing action. Myelography involves injecting contrast material into the spinal canal, which can affect the spinal cord and nerve roots. Monitoring for changes in muscle tone, such as a decrease in spasticity, helps detect potential complications early and allows for timely intervention.

Choice D reason: Performing a follow-up MRI is not the immediate priority nursing action. While follow-up imaging may be necessary to assess the results of the myelography, the immediate focus is on monitoring the patient's neurological status and ensuring their safety.

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The nurse is caring for a patient experiencing precipitous Labor. What complication will the nurse monitor this patient for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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