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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Administering saline drops into the newborn's nares is not the first action, as it can cause aspiration and irritation of the nasal mucosA. The nurse should clear the airway of the newborn before administering any medication or fluiD.
Choice B: Suctioning the newborn's mouth first and then the nose with a bulb syringe is the first and most important action, as it can remove the excess mucus and prevent obstruction and aspiration of the airway. The nurse should squeeze the bulb syringe before inserting it into the mouth or nose and release it gently to create suction. The nurse should suction the mouth before the nose to avoid pushing the mucus back into the throat.
Choice C: Placing the newborn in Trendelenburg position is not an appropriate action, as it can cause the mucus to flow back into the throat and lungs and increase the risk of aspiration and infection. The nurse should keep the newborn's head slightly lower than the chest to facilitate the drainage of the mucus.
Choice D: Performing deep suctioning of the newborn's trachea with an endotracheal tube is not an appropriate action, as it can cause trauma and inflammation of the trachea and vocal cords and increase the risk of bleeding and infection. The nurse should only perform this action if the newborn has signs of respiratory distress or meconium aspiration and under the supervision of a provider.
Correct Answer is B
Explanation
Choice A: Thromboembolic events are not prevented by methylergonovinE. Thromboembolic events are blood clots that can form in the veins or arteries and cause serious complications such as pulmonary embolism or strokE. Methylergonovine is a uterotonic agent that stimulates the contraction of the uterus and can actually increase the risk of thromboembolic events by causing vasoconstriction and hypertension.
Choice B: Postpartum hemorrhage is prevented by methylergonovinE. Postpartum hemorrhage is excessive bleeding after delivery that can result from uterine atony, retained placenta, or lacerations. Methylergonovine is a uterotonic agent that stimulates the contraction of the uterus and helps control the bleeding by compressing the blood vessels and expelling any placental fragments.
Choice C: Postpartum infection is not prevented by methylergonovinE. Postpartum infection is a bacterial infection that can affect the uterus, the vagina, the bladder, or the breast after delivery. Methylergonovine is a uterotonic agent that has no antibacterial activity and can actually increase the risk of infection by causing fever and chills.
Choice D: Hypertension is not prevented by methylergonovinE. Hypertension is high blood pressure that can cause complications such as preeclampsia, eclampsia, or strokE. Methylergonovine is a uterotonic agent that can actually cause or worsen hypertension by stimulating the alpha-adrenergic receptors and causing vasoconstriction.
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