Signs and symptoms
Total Questions : 10
Showing 10 questions, Sign in for moreA nurse is caring for a client who is in the active phase of labor and has a slow cervical dilation.
The nurse should monitor the client for which of the following complications?
Explanation
This is a rare but serious complication that occurs when the uterus tears during labor.
It can cause severe bleeding, fetal distress, and maternal shock.
It can also lead to hysterectomy or death.Uterine rupture is more likely to occur in women who have had previous cesarean sections or other uterine surgeries.
A nurse is assessing a client who has been in labor for 14 hours and has a fever of 38.2°C (100.8°F).
The nurse notes that the amniotic fluid is foul-smelling.
Which of the following actions should the nurse take first?
Explanation
The nurse should report the findings of a fever and foul-smelling amniotic fluid to the provider as soon as possible, as they may indicate an infection of the amniotic sac and fluid (chorioamnionitis).Chorioamnionitis can cause serious complications for both the mother and the baby, such as sepsis, preterm birth, and neonatal pneumonia.
Therefore, notifying the provider is the priority action.
A nurse is reviewing the electronic fetal monitor (EFM) tracing of a client who is in labor and has a prolonged deceleration of the fetal heart rate to 90/min.
The nurse should recognize that this finding indicates which of the following?
Explanation
A prolonged deceleration of the fetal heart rate to 90/min indicates acute fetal hypoxia/acidosis, which is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus.Fetal pH drops at a rate of 0.01/min during the deceleration.Causes of acute hypoxia include low maternal blood pressure, dehydration, anemia, rapid uterine contractions, placental abruption, and fetal hypoxia.
A nurse is preparing to assist with an emergency cesarean delivery for a client who has obstructed labor and excessive vaginal bleeding.
The nurse should anticipate administering which of the following medications to prevent hemorrhage?
Explanation
This medication is a uterotonic agent that stimulates the contraction of the uterus and helps prevent hemorrhage after cesarean delivery.It is especially indicated for clients who have obstructed labor and excessive vaginal bleeding, as they are at high risk of postpartum hemorrhage.
Normal ranges for uterine tone are less than 10 mm Hg at rest and less than 25 mm Hg during contractions.
Normal ranges for blood pressure are 110-140 mm Hg systolic and 60-90 mm Hg diastolic.
Normal ranges for heart rate are 60-100 beats per minute.
A nurse is evaluating the outcomes of care for a client who had prolonged labor and delivered a newborn with Apgar scores of 6 and 8 at 1 and 5 minutes, respectively.
Which of the following findings indicates a positive outcome?
Explanation
This indicates a positive outcome because meconium aspiration can cause respiratory distress and infection in newborns.Apgar scores are used to assess the health of newborns at 1 and 5 minutes after birth based on five criteria: activity, pulse, grimace, appearance, and respiration.A score of 7 to 10 is considered normal.
A nurse is caring for a client who has a history of previous cesarean delivery with a low transverse incision.
The client is in labor and wants to have a vaginal birth after cesarean (VBAC).
The nurse should monitor the client closely for signs of which complication?
Explanation
The client with any prior history of uterine surgery is at increased risk for a uterine rupture.A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration.
A nurse is reviewing the electronic fetal monitor (EFM) tracing of a client who has a ruptured uterus.
Which of the following findings would the nurse expect to see on the EFM?
Explanation
A sinusoidal pattern is a type of fetal heart rate (FHR) tracing that shows a smooth, undulating wave-like pattern with a fixed period of 3 to 5 cycles per minute and an amplitude range of 5 to 15 beats per minute.A sinusoidal pattern is associated with severe fetal anemia, hypoxia, or acidosis and indicates a poor prognosis for the fetus.
A nurse is assisting with an artificial rupture of membranes (AROM) for a client who is in active labor.
The nurse should report which of the following findings to the provider immediately?
Explanation
This is a sign of umbilical cord prolapse, which is a medical emergency that requires immediate delivery of the baby.The umbilical cord can become compressed and cut off oxygen and blood supply to the baby.
A nurse is preparing to administer oxytocin to a client who has a previous cesarean delivery with a vertical uterine incision.
The nurse should be aware that this client has an increased risk for which of the following adverse effects?
Explanation
Oxytocin is a hormone that stimulates uterine contractions and can be used to induce or augment labor.However, it also increases the risk of uterine rupture, especially in women who have a scarred uterus from a previous cesarean delivery with a vertical uterine incision.A vertical uterine incision is made in the contractile part of the uterus and is more likely to tear under stress than a low transverse incision, which is made in the lower segment of the uterus.
Normal ranges for oxytocin infusion during labor are 0.5 to 20 milliunits per minute, depending on the indication and maternal and fetal status.The infusion rate should be adjusted according to the frequency and strength of uterine contractions and the progress of cervical dilation.
A nurse is assessing a client who has a ruptured uterus.
Which of the following findings should the nurse expect? (Select all that apply.).
Explanation
A ruptured uterus is a serious complication that can cause severe bleeding, fetal distress and shock in the mother.
The symptoms of a ruptured uterus may include:
• Sudden onset of severe abdominal paindue to the tear in the uterine wall.
• Loss of uterine contractions or tonedue to the disruption of the uterine muscle.
• Vaginal bleeding (may be minimal)due to the blood loss from the uterine vessels.
• Shock (hypotension, tachycardia, pallor)due to the hemorrhage and reduced blood flow to vital organs.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for heart rate are 60 to 100 beats per minute, and for fetal heart rate are 110 to 160 beats per minute.
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