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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:

Notifying the primary care provider is important but not the immediate next step. The nurse has other immediate responsibilities to ensure the safety of the mother and baby.

Choice B rationale:

A vaginal exam could introduce bacteria into the uterus and is not the immediate next step after rupture of membranes.

Choice C rationale:

Changing the linen saver pad is not the immediate next step. While it might be necessary for the comfort of the mother, it does not address the potential risks associated with rupture of membranes.

Choice D rationale:

Checking the fetal heart rate is the correct next step. This ensures that the baby is not in distress following the rupture of membranes.

A. Implementing measures for a vaginal birth. B. Instituting continuous internal fetal monitoring. C. Assisting with artificial rupture of the membranes. D. Preparing the client for a cesarean birth.

Correct Answer is A

Explanation

Choice A rationale:

Implementing measures for a vaginal birth is a reasonable intervention as the baby is in a favorable position for a normal delivery.

Choice B rationale:

Continuous internal fetal monitoring is not necessary unless there are complications or high-risk factors present.

Choice C rationale:

Artificial rupture of the membranes can be done to induce or augment labor, but it’s not necessary in this case.

Choice D rationale:

Preparing for a cesarean birth is not necessary as the baby is in a favorable position for a vaginal birth.

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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?.

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Naxlex Comprehensive Predictor Exams

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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?.