A nurse is caring for a client who is in a trial of labor for vaginal birth after cesarean (VBAC). The client reports a sudden tearing pain in their back and side that does not feel like a uterine contraction.
Which of the following findings indicates the client may be experiencing a uterine rupture?
Observation of a sudden gush of amniotic fluid.
Hypotension with a blood pressure of 85/40 mm Hg.
Severe bradypnea with a respiratory rate of 10/min.
Palpation of the fetal presenting part in the cervical os.
The Correct Answer is B
Choice A rationale
A sudden gush of amniotic fluid typically indicates rupture of membranes (ROM), which can be spontaneous or induced. While ROM can occur during labor, it is not a direct indicator of uterine rupture, which is a catastrophic event involving the tearing of the uterine wall and often presents with different clinical signs.
Choice B rationale
Hypotension with a blood pressure of 85/40 mm Hg is a critical finding suggesting hypovolemic shock, often due to internal hemorrhage, which is a common consequence of uterine rupture. The sudden loss of maternal blood into the abdominal cavity leads to a rapid decrease in circulating blood volume and subsequent systemic hypotension.
Choice C rationale
Severe bradypnea with a respiratory rate of 10/min is not a primary indicator of uterine rupture. Bradypnea often suggests central nervous system depression, possibly from medication effects or other neurological events, but is not a direct physiological response to the acute blood loss and pain associated with a uterine tear.
Choice D rationale
Palpation of the fetal presenting part in the cervical os is a normal finding during labor progression as the fetus descends. However, if the presenting part is palpated higher or outside the uterus, it can indicate expulsion of the fetus into the abdominal cavity following a complete uterine rupture, which is an abnormal and emergent finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The vaginal contraceptive ring is designed for cyclic use, specifically to be left inserted for 3 consecutive weeks, followed by a 1-week ring-free interval. This regimen allows for a withdrawal bleed during the ring-free week, mimicking a natural menstrual cycle while maintaining contraceptive efficacy by providing continuous hormone release for 21 days.
Choice B rationale
Body weight fluctuations of 4.5 kg (10 lb) do not significantly impact the effectiveness of the vaginal contraceptive ring. The ring delivers a localized and consistent dose of hormones that is not dependent on systemic absorption influenced by minor weight changes. Therefore, contacting a provider for a new ring due to this weight change is unnecessary.
Choice C rationale
The vaginal contraceptive ring should not be washed with soap and water after each use. The ring is a single-use, disposable device designed to be inserted and remain in place for the full 3-week duration. Washing it could potentially degrade the material or interfere with the controlled release of hormones, compromising its efficacy.
Choice D rationale
The vaginal contraceptive ring does not need to be inserted immediately before sexual intercourse. It provides continuous contraceptive protection as long as it is inserted and used correctly according to the 3-week in, 1-week out schedule. Its efficacy is not tied to the timing of individual sexual acts.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Acrocyanosis, characterized by bluish discoloration of the hands and feet, is a common and usually benign finding in newborns, especially shortly after birth due to immature peripheral circulation. It does not typically indicate neonatal abstinence syndrome, which is a neurological and systemic hyperexcitability response to opioid withdrawal.
Choice B rationale
Hypotonia, or decreased muscle tone, is generally a sign of central nervous system depression or neuromuscular disorder. In contrast, newborns with neonatal abstinence syndrome typically exhibit hypertonia, characterized by increased muscle tone, tremors, and hyperreflexia, due to the overstimulation of the central nervous system following cessation of maternal opioid exposure.
Choice C rationale
An exaggerated Moro reflex, characterized by an overly robust and prolonged startle response, is a common manifestation of central nervous system irritability seen in newborns experiencing neonatal abstinence syndrome. This hyperreflexia is a direct result of the withdrawal symptoms, indicating an overactive nervous system in response to the absence of the previously supplied opioid.
Choice D rationale
Tachypnea, or rapid breathing, is a frequent finding in newborns with neonatal abstinence syndrome. This symptom is often attributed to central nervous system irritability and increased metabolic demand associated with withdrawal, leading to respiratory distress. The respiratory rate often exceeds the normal range of 30-60 breaths per minute.
Choice E rationale
A shrill-pitched cry, often described as inconsolable or high-pitched, is a classic and distinctive symptom of neonatal abstinence syndrome. This abnormal cry pattern is indicative of central nervous system irritation and dysregulation, reflecting the newborn's discomfort and hyperirritability stemming from opioid withdrawal. This cry often differs from a typical hunger or discomfort cry.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.