There are four clients in active labor in the labor suite.
Which of the clients should the nurse monitor carefully for a potential uterine rupture?
Age 15, G3 P0020, in active labor.
Age 22, G1 P0000, eclampsia.
Age 25, G4 P3003, last delivery by cesarean section.
Age 32, G2 P0100, first baby died during labor.
The Correct Answer is C
Choice A rationale
A 15-year-old, G3 P0020, although young, doesn't have an increased risk of uterine rupture related to prior surgical deliveries or other known factors.
Choice B rationale
A 22-year-old, G1 P0000 with eclampsia requires close monitoring for complications related to eclampsia but not specifically for uterine rupture.
Choice C rationale
A 25-year-old, G4 P3003 with a previous cesarean section is at increased risk for uterine rupture due to the scar from the prior surgery which could weaken under the stress of labor.
Choice D rationale
A 32-year-old, G2 P0100's history of a prior fetal demise does not specifically increase the risk of uterine rupture unless accompanied by other risk factors. .
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Correct Answer is B
Explanation
Choice A rationale
Swaddling provides warmth but doesn't address jitteriness, which may be due to hypoglycemia.
Choice B rationale
Jitteriness in a newborn can indicate hypoglycemia. Prompt glucose assessment is crucial for early detection and management.
Choice C rationale
Feeding could help with glucose levels, but without knowing the glucose status, it might not be the immediate priority.
Choice D rationale
Routine medications are important but not as urgent as addressing possible hypoglycemia in a jittery baby.
Correct Answer is A
Explanation
Choice A rationale
Massaging the fundus can help contract the uterus and reduce bleeding. Ensuring IV access is crucial for administering medications rapidly. Methylergonovine (Methergine) and oxytocin help stimulate uterine contractions and reduce postpartum hemorrhage, which can be life-threatening.
Choice B rationale
Administering pain medication might be necessary, but it doesn't address the immediate issue of uterine atony and hemorrhage. Surgical intervention is a last resort and should be prepared for only if medical management fails.
Choice C rationale
Reassessing vital signs and monitoring is important, but it doesn't provide an immediate solution to the bleeding and uterine atony. Immediate action to contract the uterus is crucial.
Choice D rationale
Contacting the attending physician is important, but immediate intervention to stop the bleeding and address uterine atony is critical to prevent further complications.