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 B
Explanation
Choice A rationale
Chronic hypertension increases the risk of complications but is not necessarily the highest risk compared to elevated blood pressure and obesity combined in pregnancy.
Choice B rationale
Elevated blood pressure and a high BMI significantly increase the risk for complications like preeclampsia, gestational diabetes, and preterm birth in pregnancy.
Choice C rationale
A 16-year-old pregnant client is at risk due to age, but not as high as the compounded risks of hypertension and obesity.
Choice D rationale
A history of fetal demise increases risk, but current elevated blood pressure and high BMI in an older client present higher immediate pregnancy complication risks.
Correct Answer is C
Explanation
Choice A rationale
While taking antipsychotics is important, the nurse’s immediate priority should be to assess for harm to the patient or infant, which poses an immediate danger.
Choice B rationale
Monitoring the infant’s health is important but secondary to ensuring the patient and infant's immediate safety from potential harm due to psychosis.
Choice C rationale
Assessing thoughts of harm is crucial in postpartum psychosis as it helps in identifying immediate risks to the patient and infant, allowing for timely interventions.
Choice D rationale
Reviewing the medical record for bipolar disorder is important for treatment planning but not as immediately critical as assessing for thoughts of harm.
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