A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
Incompetent cervix.
Postpartum hemorrhage.
Ectopic pregnancy.
Hyperemesis gravidarum.
The Correct Answer is B
Choice A rationale:
The incompetent cervix is not related to the client's current situation. An incompetent cervix refers to a weakened cervix that may result in premature dilation during pregnancy, leading to potential pregnancy loss or preterm birth. It is not relevant to the client's current stage of labour and cervical dilation.
Choice B rationale:
Postpartum haemorrhage is the correct condition to be concerned about in this situation. The client is 80% effaced and 8 cm dilated, which indicates she is in active labour. These signs of progress indicate that she is at risk for excessive bleeding after delivery, which is known as postpartum haemorrhage.
Choice C rationale:
An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This condition is not related to the client's current presentation, as she is already in active labour.
Choice D rationale:
Hyperemesis gravidarum is severe and persistent nausea and vomiting during pregnancy, usually during the first trimester. This condition is not relevant to the client's current situation, which involves active labour and cervical dilation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Bright, red vaginal discharge is not a typical manifestation of an ectopic pregnancy. Instead, it can be indicative of other conditions such as miscarriage or vaginal bleeding.
Choice B rationale:
A scaphoid abdomen is not a typical manifestation of an ectopic pregnancy. A scaphoid abdomen is seen in cases of diaphragmatic hernia, where the abdominal organs move into the chest cavity, leaving the abdomen with a sunken appearance.
Choice C rationale:
Elevated blood pressure is not a typical manifestation of an ectopic pregnancy. High blood pressure can be associated with conditions like preeclampsia but is not specifically linked to ectopic pregnancies.
Choice D rationale:
Sharp pelvic pain is a common manifestation of an ectopic pregnancy. As the fertilized egg implants outside the uterus, often in the fallopian tube, it can cause pain and discomfort.
Correct Answer is C
Explanation
Choice A rationale:
Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.
Choice B rationale:
Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.
Choice C rationale:
Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.
Choice D rationale:
Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.
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