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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labour and indicate effective uterine activity. This finding does not warrant immediate reassessment.
Choice B rationale:
Progressive sacral discomfort during contractions can be a normal part of labour as the baby descends into the birth canal. It does not necessarily indicate a need for reassessment.
Choice C rationale:
A sense of excitement and warm, flushed skin can be a common emotional and physiological response during labour, particularly as the woman reaches the final stages of delivery. This finding does not necessarily require immediate reassessment.
Choice D rationale:
"An urge to have a bowel movement during contractions”. is the correct answer because it could be an indication that the client is experiencing the urge to push, which means the baby's head is descending and nearing delivery. The nurse should reassess the client promptly to determine if she is fully dilated and ready to push.
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
Newborn weight of 2.948 kg (6 lb 8 oz) does not place the client at risk for postpartum hemorrhage. Newborn weight is not directly related to the risk of postpartum hemorrhage in the mother.
Choice B rationale:
History of uterine atony places the client at risk for postpartum hemorrhage. Uterine atony is the most common cause of postpartum hemorrhage and refers to the inability of the uterus to contract effectively after childbirth, leading to excessive bleeding.
Choice C rationale:
Labor induction with oxytocin places the client at risk for postpartum hemorrhage. Oxytocin is commonly used to induce labor or augment contractions, but it can cause uterine hyperstimulation, leading to increased risk of postpartum hemorrhage.
Choice D rationale:
History of human papillomavirus (HPV) does not place the client at risk for postpartum hemorrhage. HPV is a sexually transmitted infection and does not have a direct connection to the risk of postpartum hemorrhage.
Choice E rationale:
Vacuum-assisted delivery places the client at risk for postpartum hemorrhage. Vacuum assisted delivery involves using a vacuum device to assist in the baby's delivery, and it can cause trauma to the birth canal, leading to increased bleeding risk in the mother.
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