A nurse is caring for a client who is in active labour 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.
Uterine rupture.
Umbilical cord prolapse.
Placenta previa.
The Correct Answer is B
Choice A rationale:
Amniotic fluid embolism is a rare but serious complication during labor or immediately after delivery, where amniotic fluid, fetal cells, hair, or other debris enter the mother's bloodstream and cause a severe reaction. While it may present with sudden and severe symptoms, such as hypotension and respiratory distress, it does not typically cause uterine rupture.
Choice B rationale:
Uterine rupture is a life-threatening emergency that can occur during labor, especially in women with previous uterine surgeries or trauma. The sudden, severe lower abdominal pain, drop in blood pressure, cool skin, and pallor could indicate internal bleeding and shock, which are consistent with uterine rupture. Prolonged bradycardia on the fetal heart rate tracing suggests fetal distress due to compromised blood flow.
Choice C rationale:
Umbilical cord prolapse is another obstetric emergency that occurs when the umbilical cord slips through the cervix and gets compressed during labor, leading to fetal distress. It may cause variable decelerations in fetal heart rate, but it does not explain the maternal symptoms described in the scenario, such as the sudden, severe lower abdominal pain, hypotension, cool skin, and pallor.
Choice D rationale:
Placenta previa is a condition where the placenta covers part or all of the cervix, and it can lead to painless vaginal bleeding. While it can cause fetal distress, it does not explain the maternal symptoms like the sudden, severe lower abdominal pain, hypotension, cool skin, and pallor. Prolonged bradycardia on the fetal heart rate tracing is more suggestive of uterine rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Thiazide diuretics cause potassium and chloride loss, leading to metabolic alkalosis, not respiratory alkalosis. Hypokalemia decreases hydrogen ion excretion, increasing bicarbonate levels. Metabolic alkalosis is characterized by pH >7.45 and HCO₃⁻ >26 mEq/L rather than decreased PaCO₂.
Choice B rationale: Vomiting leads to metabolic alkalosis due to gastric acid loss. Hydrogen ion depletion increases bicarbonate concentration, shifting pH above normal. Arterial blood gases typically show increased HCO₃⁻ (>26 mEq/L) with a compensatory increase in PaCO₂ (>45 mmHg), not respiratory alkalosis.
Choice C rationale: Salicylate intoxication initially induces hyperventilation, reducing PaCO₂ levels below 35 mmHg and increasing pH above 7.45, leading to respiratory alkalosis. As toxicity progresses, metabolic acidosis may develop due to lactic acid accumulation, but early stages primarily present with respiratory alkalosis.
Choice D rationale: Hypoventilation leads to CO₂ retention, increasing PaCO₂ above 45 mmHg, forming carbonic acid (H₂CO₃) and causing respiratory acidosis. Blood gases show pH <7.35 with elevated PaCO₂, not respiratory alkalosis, which is caused by excessive CO₂ elimination through hyperventilation.
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.
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