During augmentation of labor with intravenous oxytocin (Pitocin), a multiparous client becomes pale and diaphoretic and complains of severe lower abdominal pain with a tearing sensation. An abnormal FHR tracing is noted on the monitor. The nurse should suspect:
Uterine prolapse.
Uterine rupture.
Precipitous labor.
Amniotic fluid embolus.
The Correct Answer is B
A. Uterine prolapse. Uterine prolapse occurs when the uterus descends into or outside the vagina, usually postpartum due to weakened pelvic support. It does not present with sudden, severe pain or fetal heart rate abnormalities during labor.
B. Uterine rupture. A tearing sensation, sudden severe pain, fetal heart rate abnormalities, pallor, and diaphoresis are hallmark signs of uterine rupture. This is a life-threatening emergency where the uterine wall tears, often due to prior cesarean scars, excessive oxytocin use, or grand multiparity. Immediate intervention, including emergency surgery, is required to prevent maternal and fetal death.
C. Precipitous labor. Precipitous labor is rapid labor and delivery within three hours and is not associated with severe, tearing pain. While it can cause fetal distress, it does not typically involve uterine rupture symptoms.
D. Amniotic fluid embolus. An amniotic fluid embolus presents with sudden respiratory distress, hypotension, and cardiovascular collapse due to amniotic fluid entering the maternal circulation. It does not typically cause localized severe abdominal pain or fetal distress due to uterine rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Perform vaginal exam and apply upward digital pressure to the presenting part. A prolapsed umbilical cord is an obstetric emergency that can lead to cord compression and fetal hypoxia. The priority intervention is for the nurse to manually lift the presenting part (usually the fetal head) off the cord to relieve pressure and restore blood flow. The nurse should maintain this position until an emergency cesarean section is performed.
B. Immediately turn the client to her side. Positioning changes, such as the knee-chest or Trendelenburg position, can help relieve pressure on the cord, but they are secondary to manually lifting the presenting part. While turning the client may assist, it is not the most immediate life-saving action.
C. Call the physician immediately. While notifying the provider is essential, relieving pressure on the umbilical cord takes priority. Delaying intervention to make a call could result in prolonged fetal hypoxia and compromise.
D. Place a moist, clean towel over the cord to prevent drying. Covering the cord with a moist towel helps prevent vasospasm and drying, but it does not relieve the compression that is cutting off oxygen to the fetus. The priority is to relieve pressure on the cord first before taking other measures.
Correct Answer is A
Explanation
Professor Proctor emphasizes safety as the highest priority while traveling, including when coming to class. Ensuring that students arrive safely is considered more important than strict punctuality.
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