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.

Nursing Test Bank

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Correct Answer is ["A","C"]

Explanation

Applying suprapubic pressure and assisting the provider with McRoberts maneuver are two nursing interventions that can help dislodge the impacted shoulder and facilitate the delivery of the baby.

Normal ranges for fetal heart rate are 110 to 160 beats per minute, and for maternal blood pressure are 110/70 to 140/90 mm Hg.

A. Encourage the client to express her feelings and grief B. Avoid mentioning the baby’s name or characteristics C. Tell the client that she can try again for another baby soon D. Suggest that the client should not see or hold the baby.

Correct Answer is A

Explanation

Grief is a normal and natural response to the loss of a baby, and the nurse should provide emotional support and acknowledge the client’s pain.The nurse should also respect the client’s personal, cultural, or religious needs and preferences regarding the care of the baby.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and experiencing shoulder dystocia. Which of the following actions should the nurse take? (Select all that apply.).

Correct Answer is ["A","C"]

Explanation

A nurse is providing emotional support to a client who had a prolonged labor and delivered a stillborn baby by cesarean section. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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 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?

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

A nurse is caring for a client who had a vacuum-assisted delivery due to prolonged labor and is at risk for developing a hematoma in the perineal area. Which of the following manifestations should alert the nurse to this complication?