A nurse is triaging four clients on the labor and delivery unit.
Which of the following actions should be a priority for nursing care?
Check the blood sugar of a gestational diabetic.
Assess the vaginal blood loss of a client who is recovering from a spontaneous abortion.
Assess the patellar reflexes of a client with pre-eclampsia without severe features.
Check the fetal heart rate of a client whose membranes just ruptured.
The Correct Answer is D
Choice A rationale
Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.
Choice B rationale
Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.
Choice C rationale
Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.
Choice D rationale
Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.
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Correct Answer is D
Explanation
Choice A rationale
Placental abruption involves the detachment of the placenta from the uterine wall before delivery, causing bleeding, abdominal pain, and uterine tenderness. It does not typically cause dyspnea, hypotension, frothy sputum, or loss of consciousness.
Choice B rationale
Uterine rupture is a tear in the uterine wall, often in a scarred uterus. Symptoms include severe abdominal pain, abnormal fetal heart rate, and vaginal bleeding. It can cause shock, but not frothy sputum or sudden dyspnea.
Choice C rationale
Uterine inversion occurs when the uterus turns inside out, often during placental delivery. It leads to pain, hemorrhage, and shock. Like uterine rupture, it does not cause frothy sputum or sudden dyspnea.
Choice D rationale
Anaphylactoid syndrome (amniotic fluid embolism) occurs when amniotic fluid enters the maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, fitting the scenario described.
Correct Answer is B
Explanation
Choice A rationale
Administering oxytocin during shoulder dystocia can exacerbate the problem by increasing uterine contractions, making it harder to deliver the baby's shoulder.
Choice B rationale
Flexing the client's thighs sharply toward her abdomen, known as the McRoberts maneuver, helps to widen the pelvis and can often resolve shoulder dystocia by changing the angle of the pelvic bones.
Choice C rationale
While applying oxygen is a standard practice to improve maternal and fetal oxygenation, it does not specifically address shoulder dystocia and is not a primary intervention.
Choice D rationale
Applying downward pressure on the fundus is contraindicated as it can worsen shoulder dystocia by further impacting the shoulder against the pelvic bone.