A nurse is caring for a client who is in active labor and reports sudden, severe lower abdominal pain. The nurse observes a drop in the client's blood pressure and notes cool skin and pallor. The fetal heart rate tracing shows prolonged bradycardia. Which of the following complications should the nurse suspect?
Amniotic fluid embolism
Umbilical cord prolapse
Uterine rupture
Placenta previa
The Correct Answer is C
Uterine rupture. The sudden, severe lower abdominal pain, drop in blood pressure, and signs of shock such as cool skin and pallor all point to a potential intra-abdominal hemorrhage most likely due to Uterine rupture. Additionally, the prolonged bradycardia on the fetal heart rate tracing indicates that the baby may be experiencing fetal distress due to a compromised blood supply. Amniotic fluid embolism triggers an allergic reaction, causing a sudden onset of respiratory distress, hypotension, and cardiac arrest. Option D, placenta previa, occurs when the placenta implants in the lower uterine segment, partially or completely covering the cervical os. This can lead to painless vaginal bleeding but typically does not present with sudden, severe abdominal pain or signs of shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the
abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.
Correct Answer is D
Explanation
: Rh-positive blood test results. Rho(D) immune globulin is indicated for Rh-negative women who are pregnant and for those who have had a miscarriage, ectopic pregnancy, or induced abortion. It is also indicated for Rh-negative women who give birth to Rh-positive infants. The administration of Rho(D) immune globulin prevents the Rh-negative mother from forming antibodies against Rh-positive fetal cells that may have entered her bloodstream.
Choice A, prescription for an amniocentesis, is not an indication for the administration of Rho(D) immune globulin. Choice B, anemia, and choice C, hyperemesis gravidarum, are also not indications for the administration of Rho(D) immune globulin.
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