Which of the following is the appropriate nursing care outcome for a client who suddenly develops anaphylactoid syndrome of pregnancy (ASP) during labor?
Client will be infection free at discharge.
Client will exhibit normal breathing function at discharge.
Client will exhibit normal gastrointestinal function at discharge.
Client will void without pain at discharge.
The Correct Answer is B
Choice A rationale
While infection prevention is vital, ensuring breathing function is more critical after ASP.
Choice B rationale
ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.
Choice C rationale
Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.
Choice D rationale
Voiding without pain is important, but respiratory stability takes precedence.
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Correct Answer is A
Explanation
Choice A rationale
Postpartum psychosis is a serious mental health condition that can result in delusions and hallucinations. These symptoms increase the risk of harm to the infant, so it's essential that
the mother is not left alone with the baby to ensure both their safety.
Choice B rationale
Symptoms of postpartum psychosis typically last longer than one week and require medical intervention, contrary to what is stated in this choice. Treatment usually involves
antipsychotics, mood stabilizers, and sometimes hospitalization.
Choice C rationale
Clinical response to medications can be significant in many cases, and early and aggressive treatment often leads to improvement. This statement is inaccurate and does not reflect
the current understanding of postpartum psychosis treatment.
Choice D rationale
While monitoring vital signs is essential, it is not as critical as ensuring the infant's safety given the mother’s severe mental condition. The focus should be on psychiatric
management and safety protocols rather than routine vitals alone.
Correct Answer is D
Explanation
Choice A rationale
Oxytocin is used to induce or augment labor, not typically used before an external version, which is a procedure to turn a breech baby to a head-down position.
Choice B rationale
Methylergonovine is used to prevent or control postpartum hemorrhage by inducing strong uterine contractions, not indicated before an external version.
Choice C rationale
Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not required for an external version.
Choice D rationale
Terbutaline is a tocolytic agent used to relax the uterus, making it easier to manipulate the fetus during the external version procedure.