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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice B. Single palmar creases.

Choice A rationale:

Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.

Choice B rationale:

Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.

Choice C rationale:

Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.

Choice D rationale:

Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.

A. Assess the newborn for reflex bradycardia. B. Use the bulb syringe to suction the newborn's nose. C. Place the bulb syringe in the newborn's mouth. D. Compress the bulb syringe.

Correct Answer is D,C,B,A

Explanation

The correct sequence for suctioning a newborn with a bulb syringe, according to the information provided, is as follows: 1. Compress the bulb syringe (d) to expel the air. 2. Place the bulb syringe in the newborn’s mouth © to suction the mucus. 3. Use the bulb syringe to suction the newborn’s nose (b) after the mouth has been cleared. 4. Assess the newborn for reflex bradycardia (a) following the suctioning. This sequence ensures that the airway is cleared effectively and safely, minimizing the risk of inducing bradycardia by stimulating the vagus nerve during suctioning. Always remember to perform these steps gently and to follow the guidelines and protocols of your healthcare facility.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe.

Correct Answer is D,C,B,A

Explanation

A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor which of the following findings has an adverse effect.

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A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse?

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?

A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum haemorrhage?(Select all that apply.)

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