A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has preeclampsia. Suddenly, the client reports continuous severe abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
Prolapsed cord.
Abruptio placentae.
Placenta previa.
Incompetent cervix.
Incompetent cervix.
The Correct Answer is B
Choice A rationale
Prolapsed cord involves the umbilical cord descending into the birth canal ahead of the fetus, which is a critical emergency but presents differently, typically with changes in fetal
heart rate and the cord being palpable or visible.
Choice B rationale
Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall, which can cause severe abdominal pain, vaginal bleeding, and is a medical
emergency requiring immediate intervention to prevent maternal and fetal complications.
Choice C rationale
Placenta previa involves the placenta partially or completely covering the cervical opening, which can cause painless vaginal bleeding but does not typically present with severe
abdominal pain.
Choice D rationale
Incompetent cervix is associated with painless cervical dilation and potential preterm labor but not typically with severe abdominal pain and acute vaginal bleeding as seen with
abruptio placentae
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Correct Answer is C
Explanation
Choice A rationale
Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.
Choice B rationale
Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.
Choice C rationale
Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.
Choice D rationale
Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.
Correct Answer is B
Explanation
Choice A rationale
Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.
Choice B rationale
Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.
Choice C rationale
Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.
Choice D rationale
Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.