A delirious client is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets.
The nurse monitors this client carefully for which of the following intrapartum complications?
Prolonged labor.
Prolapsed cord.
Abruptio placentae.
Retained placenta
Retained placenta
The Correct Answer is C
Choice A rationale
Prolonged labor is not directly linked to drug use and does not present as an immediate complication.
Choice B rationale
Prolapsed cord is not associated with substance abuse and lacks direct connection to this scenario.
Choice C rationale
Cocaine use heightens the risk of abruptio placentae, a serious condition where the placenta detaches prematurely.
Choice D rationale
Retained placenta is a concern but less likely than abruptio placentae in the context of cocaine use.
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Correct Answer is A
Explanation
Choice A rationale
Blood pressure of 160/110 indicates severe preeclampsia and warrants immediate intervention to prevent complications. Stopping oxytocin is part of the management of severe
preeclampsia to avoid exacerbating the condition.
Choice B rationale
Frequency of contractions every 3 minutes is within the normal range during labor induction and does not warrant stopping the infusion unless there are other concerns.
Choice C rationale
A fetal heart rate of 155 bpm with early decelerations may require close monitoring but does not necessarily warrant stopping the oxytocin infusion. Early decelerations are typically a
normal physiological response.
Choice D rationale
Frequency of contractions every 3 minutes is expected during active labor and is generally not a cause to stop the oxytocin infusion. The nurse should continue to monitor the labor
progression closely.
Correct Answer is B
Explanation
Choice A rationale
While massaging the fundus and ensuring IV access are correct initial actions, methylergonovine (Methergine) is typically used for patients without hypertensive history due to its
potential to raise blood pressure.
Choice B rationale
This option correctly identifies initial steps and appropriate medication. Carboprost-tromethamine (Hemabate) is effective in controlling postpartum hemorrhage and can be safely
used in patients with hypertension when oxytocin is insufficient.
Choice C rationale
Quantifying blood loss is essential but it is not an immediate priority when the patient is showing signs of significant bleeding and instability. Immediate intervention to control bleeding
takes precedence.
Choice D rationale
Assisting the patient to the restroom and then massaging the fundus overlooks the immediate need to control bleeding. This approach may delay necessary treatment and increase
the risk of further hemorrhage.
Choice E rationale
Straight catheterization and oxytocin maintenance are part of the management of postpartum hemorrhage but do not address the immediate need to ensure uterine contraction and
control active bleeding as effectively as the initial steps outlined in Choice B. .