A nurse is monitoring a client who had a vaginal birth after cesarean (VBAC) delivery.

The nurse notes that the client has a boggy uterus, heavy vaginal bleeding, and signs of hypovolemic shock.

The nurse suspects that the client has a concealed uterine rupture.

What is an appropriate nursing action for this client?

Massage the fundus and administer methylergonovine as prescribed

Insert an indwelling urinary catheter and measure urine output

Apply ice packs to the perineum and elevate the client’s legs

Start a large-bore IV line and administer crystalloid fluids as prescribed.

Answer and Explanation

The Correct Answer is D

This is because the client has signs of concealed uterine rupture, which is a rare but serious complication of VBAC delivery. Concealed uterine rupture occurs when the uterus tears through the endometrium and myometrium, but the peritoneum remains intact. This can cause heavy vaginal bleeding, hypovolemic shock, and fetal distress. The priority nursing action is to restore the client’s blood volume and prepare for emergency surgery to deliver the fetus and repair the uterus.

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Correct Answer is D

Explanation

Uterine rupture can cause fetal distress and hypoxia, which can slow down the fetal heart rate.

Fetal bradycardia is a sign of a serious complication that requires immediate intervention.

A. A boggy uterus that does not respond to massage B. A pulse rate of 120 beats per minute C. A blood pressure of 90/60 mm Hg D. A lochia flow heavier than a normal menstrual period

Correct Answer is A

Explanation

A boggy uterus that does not respond to massage is an early indicator of postpartum hemorrhage.

A boggy uterus means that the uterus is not contracting properly after delivery, which can lead to excessive bleeding from the site where the placenta was attached.This condition is called uterine atony and it is the most common cause of postpartum hemorrhage.

Massage can help stimulate the uterus to contract and stop the bleeding, but if it does not work, other interventions are needed.

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Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client who has prolonged labor and suspects uterine rupture. Which of the following findings should alert the nurse to this complication?

Correct Answer is D

Explanation

A nurse is evaluating a client who has prolonged and obstructed labor for signs of postpartum hemorrhage. Which of the following findings is an early indicator of postpartum hemorrhage?

Correct Answer is A

Explanation

A nurse is counseling a client who has a small pelvis and wants to have a vaginal delivery. Which of the following factors should the nurse consider when discussing the possibility of vaginal birth after cesarean (VBAC)?

A nurse is preparing to assist with an emergency cesarean delivery for a client who has a ruptured uterus. Which of the following equipment should the nurse have readily available? (Select all that apply.)

A nurse is reviewing the partograph of a client in labor. The nurse notes that the cervical dilation curve is above the alert line and below the action line. What does this indicate?

A nurse is caring for a client who has prolonged labor and is at risk for infection. Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

A nurse is assessing a client who is in labor and has been pushing for 3 hours with no progress. The nurse should identify that this client is at risk for which of the following complications? (Select all that apply.).

A nurse is assessing a client who had a prolonged labor and is at risk for uterine atony. Which of the following findings should indicate to the nurse that the client has this condition? Select all that apply.

A nurse is providing discharge teaching to a client who had a ruptured uterus and a hysterectomy during labor. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is assessing a client who is in labor and notes that the fetal head is visible at the vaginal opening but does not advance with pushing. The nurse should identify this finding as which of the following?