A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has gestational hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
Placenta previa
Incompetent cervix
Prolapsed cord
Abruptio placentae
The Correct Answer is D
Choice A) Placenta previa is incorrect because this is not a likely complication for a client who has gestational hypertension and reports continuous abdominal pain and vaginal bleeding. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. It can cause painless, bright red bleeding in the third trimester, especially after intercourse or a pelvic exam. However, it does not cause abdominal pain, as the bleeding is not associated with uterine contractions or separation. Moreover, it is not related to gestational hypertension, which is a condition that causes high blood pressure during pregnancy. Therefore, this response is irrelevant and inaccurate.
Choice B) Incompetent cervix is incorrect because this is not a possible complication for a client who is at 36 weeks of gestation and has gestational hypertension and reports continuous abdominal pain and vaginal bleeding.
Incompetent cervix is a condition where the cervix is weak and unable to hold the pregnancy, leading to premature dilation and delivery. It can cause painless, watery vaginal discharge or spotting in the second trimester, followed by rupture of membranes and labor. However, it does not cause abdominal pain or heavy bleeding, as the cervix does not tear or detach from the uterus. Moreover, it is not related to gestational hypertension, which is a condition that causes high blood pressure during pregnancy. Therefore, this response is irrelevant and inaccurate.
Choice C) Prolapsed cord is incorrect because this is not a common complication for a client who has gestational hypertension and reports continuous abdominal pain and vaginal bleeding. Prolapsed cord is a condition where the umbilical cord slips through the cervix and into the vagina before the baby, compressing the cord and cutting off the blood supply and oxygen to the baby. It can cause variable or prolonged fetal heart rate decelerations, visible or palpable cord in the vagina, or fetal distress. However, it does not cause abdominal pain or bleeding, as the cord does not rupture or bleed. Moreover, it is not related to gestational hypertension, which is a condition that causes high blood pressure during pregnancy. Therefore, this response is irrelevant and inaccurate.
Choice D) Abruptio placentae is correct because this is a probable complication for a client who has gestational hypertension and reports continuous abdominal pain and vaginal bleeding. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, causing hemorrhage and hypoxia for the mother and the baby. It can cause severe, constant abdominal pain, dark red bleeding, uterine tenderness or rigidity, fetal distress or demise, or maternal shock or coagulopathy. It can be triggered by gestational hypertension, which is a condition that causes high blood pressure during pregnancy and increases the risk of placental abruption by 25%. Therefore, this response is relevant and accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice a) Have the parent fold the infant's arms across the chest is incorrect because this is not a helpful way to calm a preterm infant. Folding the arms across the chest can restrict the infant's breathing and movement, and may increase their stress and discomfort. Preterm infants need gentle and supportive touch, not restraint or pressure.
Choice b) Encourage the parent to place the infant back in the warmer is incorrect because this is not a necessary or beneficial action for a preterm infant who is showing signs of overstimulation. Placing the infant back in the warmer can interrupt the bonding and attachment process between the parent and the infant, and may make the infant feel more isolated and insecure. Preterm infants need close and frequent contact with their parents, not separation or detachment.
Choice c) Encourage the parent to do kangaroo care is correct because this is an effective and evidence-based method of soothing and stabilizing a preterm infant who is experiencing overstimulation. Kangaroo care is a technique where the parent holds the infant skin-to-skin on their chest, providing warmth, comfort, and security. Kangaroo care can reduce the infant's stress hormones, lower their heart rate and blood pressure, improve their oxygenation and breathing, enhance their growth and development, and strengthen their bond with their parent.
Choice d) Cover the infant with a warm bed blanket is incorrect because this is not a sufficient or optimal way to comfort a preterm infant who is displaying signs of overstimulation. Covering the infant with a warm bed blanket can provide some warmth and protection, but it does not offer the same benefits as kangaroo care. A warm bed blanket cannot mimic the parent's heartbeat, voice, smell, and movement, which are essential for the infant's emotional and physiological well-being. Preterm infants need human touch and interaction, not just physical warmth.
Correct Answer is D
Explanation
Choice A) Obtain an oxygen saturation: This is not a priority action because it does not address the underlying cause of the respiratory distress, which is meconium aspiration. Meconium aspiration can cause airway obstruction, inflammation, infection, and pulmonary hypertension in the newborn. Oxygen saturation may be low, but it is not a reliable indicator of the severity of the condition.
Choice B) Stimulate the baby to increase respirations: This is not a priority action because it may worsen the respiratory distress by increasing the work of breathing and causing more meconium to be aspirated. Stimulation may also cause stress and hypoxia in the newborn.
Choice C) Prepare to initiate ECMO: This is not a priority action because it is a last resort treatment for severe cases of meconium aspiration syndrome that do not respond to conventional therapies. ECMO stands for extracorporeal membrane oxygenation, which is a form of life support that bypasses the lungs and provides oxygen to the blood.
ECMO has many risks and complications, such as bleeding, infection, and organ damage. It should only be used when other options have failed and with the consent of the parents.
Choice D) Notify the provider at once: This is the correct action because it allows for prompt assessment and intervention by the provider, who can initiate appropriate treatments for meconium aspiration syndrome. These may include suctioning of the airway, administration of antibiotics, surfactant, or inhaled nitric oxide, and mechanical ventilation . Early treatment can improve the outcomes and reduce the complications of meconium aspiration syndrome.
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