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While waiting for the placenta to deliver during the third stage of labor, the nurse must assess the new mother's vital signs every 15 minutes.
What sign would indicate impending shock?.

Bradypnea and hypertension.

Tachycardia and a falling blood pressure.

Tachypnea and a widening pulse pressure.

Bradycardia and auscultation of fluid in the base of the lungs.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Bradypnea and hypertension are not typically signs of impending shock.

Choice B rationale:

Tachycardia and a falling blood pressure are classic signs of shock as the body tries to compensate for the decreased blood flow.

Choice C rationale:

Tachypnea and a widening pulse pressure can be signs of shock, but they are not as indicative as tachycardia and a falling blood pressure.

Choice D rationale:

Bradycardia and auscultation of fluid in the base of the lungs are not typically signs of impending shock.

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Correct Answer is D

Explanation

Choice A rationale:

Checking for a compressed umbilical cord is important as it can cause fetal distress. However, it’s not the first step in response to abnormal EFM tracing.

Choice B rationale:

Preparing for an emergency cesarean birth might be necessary if the abnormality persists and indicates fetal distress. But it’s not the immediate first step.

Choice C rationale:

Documenting the finding is part of the nursing process, but immediate interventions to address the abnormality take precedence.

Choice D rationale:

Helping the woman change positions can relieve pressure on the umbilical cord, potentially resolving the abnormality. This is often the first intervention.

A. "Time isn't important; your health and the baby's health are key.”. B. "It will depend on how big the baby is when you go into labor.”. C. "It's difficult to predict how your labor will progress, but we'll be there for you the entire time.”. D. "Since this is your first pregnancy, you can estimate it will be about 10 hours.”.

Correct Answer is C

Explanation

Choice A rationale:

This statement emphasizes the importance of health over time, which is true. However, it doesn’t directly answer the woman’s question about the duration of labor.

Choice B rationale:

The size of the baby can influence labor duration, but it’s not the only factor. Other factors like the woman’s health, age, and labor progression also matter.

Choice C rationale:

This response is supportive and honest. It acknowledges the unpredictability of labor while assuring the woman of continuous support.

Choice D rationale:

While it’s true that first-time mothers may have longer labors, predicting a specific duration like 10 hours isn’t accurate or helpful.

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While waiting for the placenta to deliver during the third stage of labor, the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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While waiting for the placenta to deliver during the third stage of labor, the nurse must assess the new mother's vital signs every 15 minutes.
What sign would indicate impending shock?.