A) Disseminated intravascular coagulation (DIC):
Abruptio placentae is a condition characterized by the premature separation of the placenta from the uterine wall. It can lead to significant bleeding and release of thromboplastin, which triggers widespread clotting within small blood vessels throughout the body. As a result, the client is at risk for developing DIC, a serious condition characterized by both widespread clotting and bleeding. Petechiae and bleeding around the IV access site are signs that the client may be experiencing abnormal clotting and hemorrhage, which are characteristic of DIC.

B) Preeclampsia:
Preeclampsia is a hypertensive disorder of pregnancy characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. While preeclampsia is a potential complication of pregnancy, it is not directly associated with abruptio placentae.

C) Anaphylactoid syndrome of pregnancy (Amniotic fluid embolism):
Anaphylactoid syndrome of pregnancy, also known as amniotic fluid embolism, is a rare but potentially life-threatening obstetric emergency. It occurs when amniotic fluid, fetal cells, or other debris enter the maternal circulation, leading to a systemic inflammatory response. While it can cause sudden and severe symptoms, such as hypotension, respiratory distress, and cardiovascular collapse, it is not directly related to the bleeding and clotting abnormalities seen in abruptio placentae.

D) Puerperal infection:
Puerperal infection refers to infections that occur following childbirth. While infection is a potential complication after any delivery, it is not directly associated with the bleeding and clotting abnormalities seen in abruptio placentae.

Answer: B, C, D, E

Rationale:

A) Massage a firm fundus: If the fundus is already firm, routine massage is not necessary. Instead, the nurse should monitor the fundus for firmness and position. Massaging is indicated only if the fundus is boggy or atonic to promote uterine contraction.

B) Determine whether the fundus is midline: Checking the position of the fundus is essential to assess for potential complications. A fundus that is not midline could indicate bladder distention, which can interfere with uterine contraction and lead to postpartum hemorrhage.

C) Document fundal height: Documenting the height of the fundus is important for monitoring uterine involution. The fundus should be at the level of the umbilicus 1-2 hours postpartum, and any deviation from expected findings should be noted for ongoing assessment.

D) Observe the lochia during palpation of fundus: Observing lochia during fundal assessment helps identify potential complications such as excessive bleeding or clots. It is crucial for the nurse to monitor lochia in conjunction with fundal assessment to ensure appropriate postpartum recovery.

E) Administer methylergonovine maleate if the uterus is boggy: Methylergonovine is indicated for uterine atony (a boggy uterus) to promote uterine contractions and reduce the risk of postpartum hemorrhage. If the fundus is found to be boggy during assessment, administration of this medication should be anticipated.

A) The posterior fontanel is palpable:
This statement is not directly related to station. The fontanelles are soft spots on the fetal skull used to assess fetal head position, but they are not specifically related to station.

B) The lowermost portion of the fetus is at the level of the ischial spines:
In obstetrics, station refers to the relationship between the presenting part of the fetus and the maternal ischial spines. When the presenting part is at 0 station, it means that the lowest part of the fetus (usually the head) is at the level of the maternal ischial spines. This is a significant landmark indicating the progress of labor. As labor progresses, the fetus descends further into the pelvis, with stations progressing from -3 to +3.

C) The fetal head is in the left occiput posterior position:
The station does not provide information about the fetal head position. Left occiput posterior position refers to the position of the fetal head in relation to the maternal pelvis, which is determined separately through pelvic examinations.

D) The largest fetal diameter has passed through the pelvic outlet:
While 0 station indicates engagement of the fetal head in the pelvis, it does not necessarily mean that the largest fetal diameter has passed through the pelvic outlet. Labor continues until the entire fetus is delivered through the birth canal, which occurs as labor progresses through the different stages.

A) The posterior fontanel is palpable:
This statement is not directly related to station. The fontanelles are soft spots on the fetal skull used to assess fetal head position, but they are not specifically related to station.

B) The lowermost portion of the fetus is at the level of the ischial spines:
In obstetrics, station refers to the relationship between the presenting part of the fetus and the maternal ischial spines. When the presenting part is at 0 station, it means that the lowest part of the fetus (usually the head) is at the level of the maternal ischial spines. This is a significant landmark indicating the progress of labor. As labor progresses, the fetus descends further into the pelvis, with stations progressing from -3 to +3.

C) The fetal head is in the left occiput posterior position:
The station does not provide information about the fetal head position. Left occiput posterior position refers to the position of the fetal head in relation to the maternal pelvis, which is determined separately through pelvic examinations.

D) The largest fetal diameter has passed through the pelvic outlet:
While 0 station indicates engagement of the fetal head in the pelvis, it does not necessarily mean that the largest fetal diameter has passed through the pelvic outlet. Labor continues until the entire fetus is delivered through the birth canal, which occurs as labor progresses through the different stages.

A) A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors:
Fine tremors can be a common side effect of terbutaline, a tocolytic medication used to inhibit preterm labor. While tremors should be monitored, they are not typically considered a critical finding requiring immediate provider notification, especially if the tremors are mild.

B) A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes:
While 2+ proteinuria and 2+ patellar reflexes are indicative of preeclampsia and warrant ongoing monitoring, they are not immediately life-threatening findings requiring urgent provider notification. However, they should be documented and followed up as part of routine preeclampsia management.

C) A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache:
Epigastric pain and unresolved headache are concerning symptoms in a client with preeclampsia, indicating potential complications such as HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) or worsening preeclampsia. These symptoms can be indicative of severe maternal complications, and immediate provider notification is necessary for further evaluation and management to prevent maternal morbidity and mortality.

D) A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions:
Irregular, frequent contractions at 32 weeks of gestation could indicate preterm labor, which is significant and requires assessment and intervention. However, in this case, the contractions are not accompanied by other signs of impending preterm birth, such as cervical changes or rupture of membranes. While this situation requires attention and timely assessment, it may not require immediate provider notification unless other concerning signs or symptoms develop.

A) Massage a firm fundus:
After a vaginal delivery, it is essential for the nurse to massage the fundus to help it contract and prevent postpartum hemorrhage. Massaging a firm fundus helps to ensure that the uterus remains contracted, which reduces the risk of excessive bleeding.

B) Determine whether the fundus is midline:
Assessing the fundus to determine if it is midline is crucial after a vaginal delivery. A midline fundus suggests proper involution of the uterus. If the fundus is deviated from the midline, it may indicate uterine atony or other complications that need to be addressed.

C) Document fundal height:
While documenting fundal height is a routine part of postpartum assessment, it is not typically done immediately after delivery. Fundal height documentation is more relevant in the postpartum period when assessing uterine involution over time.

D) Observe the lochia during palpation of the fundus:
Observing the lochia (vaginal discharge after childbirth) during palpation of the fundus is important to assess for the amount, color, and consistency of lochia. This helps the nurse to monitor for signs of postpartum bleeding and assess the progression of involution.

E) Administer methylergonovine maleate if the uterus is boggy:
If the uterus feels boggy (indicating uterine atony), the nurse should administer uterotonic medication, such as methylergonovine maleate, to promote uterine contraction and prevent postpartum hemorrhage.

A) The client reports profuse itching:
Pruritus (itching) is a common side effect of opioid medications and epidural analgesia. While it is uncomfortable for the client, it is not typically a life-threatening condition. Itching can often be managed with antihistamines or by reducing the opioid dose, but it is not as urgent as addressing hypotension.
B) Blood pressure 80/56 mm Hg:
In a client receiving opioid epidural analgesia during labor, hypotension is a potential side effect due to sympathetic blockade. This can lead to reduced perfusion to vital organs and the fetus. Therefore, the nurse's priority is to address the low blood pressure promptly to prevent maternal and fetal compromise.

C) The client reports weakness of the lower extremities:
Weakness of the lower extremities can occur due to the effects of the epidural analgesia. While it should be monitored, it is not as immediately concerning as hypotension, which can lead to compromised perfusion.

D) Temperature 38.2°C (100.8°F):
While an elevated temperature can indicate a fever, it is not typically an immediate concern unless other signs of infection or labor complications are present. In this scenario, the priority is to address the low blood pressure to prevent maternal and fetal compromise.

Answer: B. Assist the client to breathe into a paper bag.

Rationale:

A) Administer oxygen via nasal cannula: Oxygen is generally not indicated for symptoms of lightheadedness and tingling caused by hyperventilation. These symptoms are often due to a reduction in carbon dioxide levels from rapid breathing, not a lack of oxygen.

B) Assist the client to breathe into a paper bag: Breathing into a paper bag helps the client rebreathe carbon dioxide, which can counteract the effects of hyperventilation, relieving symptoms like lightheadedness and tingling. This approach helps restore the body’s CO₂ balance more effectively.

C) Instruct the client to increase her respiratory rate to more than 42 breaths per min: Increasing the respiratory rate would likely worsen hyperventilation, as it would further reduce carbon dioxide levels, leading to increased symptoms of dizziness and tingling.

D) Have the client tuck her chin to her chest: Tucking the chin does not address hyperventilation or its symptoms. While it can be helpful for certain positions during labor, it would not resolve the issues caused by excessive CO₂ loss in this case.

C) A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache:
Epigastric pain and unresolved headache are signs of worsening preeclampsia, indicating possible impending eclampsia, a severe complication characterized by seizures. These symptoms suggest a significant deterioration in the client's condition and require immediate medical attention to prevent serious maternal and fetal complications.

A) A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors:
Fine tremors are a common side effect of terbutaline, which is often used to suppress preterm labor. While tremors can be uncomfortable for the client, they are not typically life-threatening and can often be managed without immediate medical intervention.

B) A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes:
While proteinuria and increased reflexes are indicative of preeclampsia, they are not immediate concerns unless other severe symptoms are present. However, the combination of epigastric pain and unresolved headache in a client with preeclampsia indicates a worsening condition that requires urgent medical attention.

D) A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions:
While tearfulness and irregular, frequent contractions should be assessed, they are not typically indicators of an immediately life-threatening condition. In this scenario, the client's symptoms of epigastric pain and unresolved headache are more concerning and require immediate reporting to the healthcare provider.

A) The client is carrying more than one fetus:
This condition is known as polyzygotic multiples (e.g., twins, triplets) and is not the definition of polyhydramnios. Polyhydramnios refers specifically to the excessive accumulation of amniotic fluid in a singleton pregnancy.

B) There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid:
An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid is associated with neural tube defects and other fetal abnormalities. However, this is not the definition of polyhydramnios.

C) The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor:
While polyhydramnios can sometimes be associated with fetal anomalies, growth restriction, or fetal distress during labor, it is not the primary definition of the condition. Polyhydramnios itself refers to the excessive accumulation of amniotic fluid, and its presence does not always indicate fetal anomalies or distress. However, these associations may require further evaluation and monitoring during pregnancy.

D) An excessive amount of amniotic fluid is present:
Polyhydramnios is a condition characterized by an excessive accumulation of amniotic fluid around the fetus. This excess fluid can lead to complications during pregnancy and labor, including preterm labor, premature rupture of membranes, and postpartum hemorrhage. It can also be associated with maternal diabetes, fetal anomalies, or other underlying maternal or fetal conditions.