If the nurse suspects a patient has experienced anaphylactoid syndrome of pregnancy (amniotic fluid embolus), which of the following is the priority nursing intervention?
Correct coagulation failure by giving platelets
Provide emotional support to the woman and her family.
Maintain cardiac output and entice intakes & output.
Administer oxygen by tight face mask B-10L/min.
The Correct Answer is D
A. Correct coagulation failure by giving platelets. Anaphylactoid syndrome of pregnancy (amniotic fluid embolism) can cause disseminated intravascular coagulation (DIC), but correcting coagulation abnormalities is not the immediate priority. The first intervention should focus on oxygenation and stabilizing the cardiovascular system.
B. Provide emotional support to the woman and her family. While emotional support is important, this is not the priority in a life-threatening emergency. The focus should be on immediate resuscitation efforts to prevent maternal and fetal death.
C. Maintain cardiac output and assess intake & output. Maintaining cardiac output is critical, but this is secondary to oxygenation. The initial response should be administering high-flow oxygen to improve maternal and fetal oxygenation before managing hemodynamic stability.
D. Administer oxygen by tight face mask 8-10L/min. Amniotic fluid embolism causes sudden respiratory distress, hypoxia, and cardiovascular collapse. Immediate high-flow oxygen delivery is the first and most critical intervention to improve oxygenation, support cardiac function, and prevent further complications.
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 D
Explanation
A. Tell the client to take a warm shower, rest, and call back tomorrow. While rest and hydration can sometimes help with mild discomfort, this client’s symptoms—pelvic pressure, low back pain, abdominal pain, and increased vaginal discharge—are concerning for preterm labor and require immediate evaluation. Delaying care could increase the risk of preterm birth.
B. Schedule an appointment for the client at the clinic tomorrow. Waiting until the next day is not appropriate, as preterm labor is an urgent condition that needs immediate assessment to prevent premature birth. Prompt intervention may allow for tocolytic therapy or steroid administration to improve fetal lung maturity if preterm birth is imminent.
C. Instruct the client to drink cranberry juice and call if she experiences a fever. Cranberry juice is sometimes used to prevent urinary tract infections (UTIs), but this client’s symptoms are more indicative of preterm labor rather than an infection. Fever is not a defining symptom of preterm labor, and delaying care could result in complications.
D. Instruct the client to go to labor triage at the hospital for evaluation. This is the best response because the symptoms suggest possible preterm labor. Evaluation in the hospital can include cervical checks, fetal monitoring, and tests such as fetal fibronectin (fFN) to assess the risk of preterm birth. Immediate intervention can help delay labor and improve neonatal outcomes.
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