A nurse is providing care for a patient who is in labor.
After reviewing the patient’s medical history, vital signs, nurse’s notes, and diagnostic results, which of the following complications should the nurse identify that the patient is at risk of developing?
Chorioamnionitis
Preeclampsia
Gestational diabetes
Preterm labor
The Correct Answer is A
Choice A rationale
Chorioamnionitis. Based on the information provided, the patient is at risk of developing chorioamnionitis, which is an infection of the membranes surrounding the fetus.
Choice B rationale
Preeclampsia. There is no information provided that would indicate the patient is at risk of developing preeclampsia.
Choice C rationale
Gestational diabetes. There is no information provided that would indicate the patient is at risk of developing gestational diabetes.
Choice D rationale
Preterm labor. There is no information provided that would indicate the patient is at risk of developing preterm labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If a client reports feeling down and sad, having no energy, and wanting to cry, the nurse’s priority action should be to ask the client if she has considered harming her newborn. This is because these symptoms may indicate postpartum depression, a serious condition that can lead to harm to both the mother and the baby if left untreated.
Choice B rationale
While reinforcing postpartum and newborn care discharge teaching is important, it is not the priority action in this situation. The client’s emotional health needs to be addressed first.
Choice C rationale
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action in this situation. The client’s immediate emotional health needs to be addressed first.
Choice D rationale
Anticipating a prescription by the provider for an antidepressant may be part of the treatment plan for this client, but it is not the priority action. The nurse first needs to assess the safety of the client and her newborn.
Correct Answer is C
Explanation
Choice A rationale
Monitoring axillary temperature is important for all newborns to prevent hypothermia. However, it is not the priority intervention for a newborn who is small for gestational age (SGA). These newborns are at a higher risk for hypoglycemia due to decreased stores of glycogen and a lower rate of gluconeogenesis.
Choice B rationale
Monitoring weight is important for all infants, and ongoing monitoring is important for infants who are SGA. However, it is not the priority intervention for this client at this time.
Choice C rationale
This is the correct answer. Newborns who are SGA are at a higher risk for hypoglycemia. Therefore, monitoring of blood glucose levels is a priority intervention.
Choice D rationale
Providing age-appropriate stimulation is important for all newborns. However, it is not the priority intervention for a newborn who is SGA2.
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