A nurse is reviewing charts for clients who have a diagnosis of placental abruption. Which of the following clients needs an emergent cesarean section?
Client who is at 32 weeks of gestation, has a blood pressure of 138/86 mm Hg, and a heart rate of 71/min with a category I fetal heart tracing.
Client who is at 39 weeks of gestation, has a blood pressure of 122/88 mm Hg, and a pulse of 88/min with a fetal demise.
Client who is at 38 weeks of gestation, has a fetal demise and is hemorrhaging, and has a cervix dilated at 4 cm.
Client who is at 37 weeks of gestation, has a blood pressure of 116/68 mm Hg, a pulse of 72/min, and has a category I fetal heart tracing with cervical dilation at 3 cm.
The Correct Answer is C
Choice A rationale
This client's vital signs are within normal ranges for 32 weeks of gestation. A category I fetal heart tracing indicates normality, suggesting no immediate need for an emergent cesarean section.
Choice B rationale
A fetal demise at 39 weeks of gestation does not necessitate an emergent cesarean section, as the fetus is no longer viable, and other delivery methods can be considered based on the mother's condition.
Choice C rationale
Hemorrhaging at 38 weeks with a fetal demise and cervix dilated at 4 cm indicates a medical emergency. Rapid intervention, including a cesarean section, is necessary to control bleeding and protect the mother’s life.
Choice D rationale
Normal vital signs and a category I fetal heart tracing with cervical dilation at 3 cm at 37 weeks indicate no immediate need for an emergent cesarean section, as labor can proceed naturally under observation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Explaining that the newborn is no longer in pain may not facilitate grieving, as it does not acknowledge the emotional connection and grief the parents are experiencing.
Choice B rationale
Sharing the nurse's own experiences and feelings may shift the focus away from the client's emotions, potentially hindering their grieving process.
Choice C rationale
Avoiding calling the newborn by their name can create a sense of detachment and may prevent the client from fully processing their grief.
Choice D rationale
Allowing the client to hold or be with their newborn provides a tangible connection, facilitating the grieving process and helping them come to terms with their loss.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
CBC will detect abnormalities such as anemia or infection, which may correlate with preeclampsia or HELLP syndrome.
Choice B rationale
Elevated AST and ALT levels indicate liver damage, a potential sign of severe preeclampsia or HELLP syndrome.
Choice C rationale
Serum creatinine helps assess kidney function, as preeclampsia can impair renal perfusion leading to elevated levels.
Choice D rationale
Fetal ultrasound assesses fetal growth, amniotic fluid volume, and placental function, critical in monitoring preeclampsia.
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