A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks of gestation and reports continuous abdominal pain and dark red vaginal bleedinG. The tocodynamometer shows low amplitude high frequency uterine activity. The nurse should identify that the client is likely experiencing which of the following complications? (Select onE.:
Prolapsed cord
Premature rupture of membranes
Abruptio placentae
Placenta previa
The Correct Answer is C
Choice A: Prolapsed cord is not a likely complication, as it is characterized by a sudden onset of severe variable decelerations of the fetal heart rate and a visible or palpable cord in the vaginA. The nurse should identify a prolapsed cord as a medical emergency and perform immediate interventions to relieve the cord compression and deliver the fetus.
Choice B: Premature rupture of membranes is not a likely complication, as it is characterized by a gush or a trickle of clear or yellowish fluid from the vagina and a positive nitrazine or fern test. The nurse should identify premature rupture of membranes as a risk factor for infection and monitor the fetal heart rate and the maternal temperaturE.
Choice C: Abruptio placentae is a likely complication, as it is characterized by continuous abdominal pain and dark red vaginal bleeding and a board-like abdomen. The nurse should identify abruptio placentae as a life-threatening condition that involves the premature separation of the placenta from the uterine wall and can cause fetal distress and maternal hemorrhagE.
Choice D: Placenta previa is not a likely complication, as it is characterized by painless bright red vaginal bleeding and a soft and relaxed uterus. The nurse should identify placenta previa as a condition that involves the abnormal implantation of the placenta near or over the cervical os and can cause fetal hypoxia and maternal hemorrhagE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct Answer is A
Explanation
Choice A reason: This is the correct action because a full bladder can cause the uterus to be displaced and prevent it from contracting properly, leading to uterine atony and excessive bleedinG. Asking the client to empty her bladder can help the fundus to return to the midline and reduce the lochiA.
Choice B reason: This is not the correct action because the client's temperature is within the normal range for the first 24 hours postpartum. A slight elevation in temperature can be due to dehydration, exertion, or milk production. The nurse should monitor the client's temperature and encourage fluid intake, but it is not a priority action.
Choice C reason: This is not the correct action because increasing IV fluids can cause fluid overload and worsen the bleedinG. The nurse should assess the client's fluid status and adjust the IV rate accordingly, but it is not a priority action.
Choice D reason: This is not the correct action because encouraging the client to nurse more frequently can stimulate oxytocin release and cause more uterine contractions and bleedinG. The nurse should support the client's breastfeeding practices, but it is not a priority action.
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