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Which of the following is the appropriate nursing care outcome for a client who suddenly develops anaphylactoid syndrome of pregnancy (ASP) during labor?

A.

Client will be infection free at discharge.

B.

Client will exhibit normal breathing function at discharge.

C.

Client will exhibit normal gastrointestinal function at discharge.

D.

Client will void without pain at discharge.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Bleeding is typically not associated with a vaginal hematoma; it is more indicative of other postpartum complications such as uterine atony or retained placenta fragments.

Choice B rationale

Warmth is usually associated with infection or inflammation. A hematoma is a collection of clotted blood outside the blood vessels, not typically characterized by warmth.

Choice C rationale

Redness might be seen in cases of infection or inflammation. A vaginal hematoma is a localized collection of blood and does not inherently cause redness.

Choice D rationale

Pain is a common symptom of a vaginal hematoma due to the pressure and swelling from the accumulated blood.

Correct Answer is B

Explanation

Choice A rationale

Contraction duration less than 40 seconds doesn't define tachysystole. Tachysystole focuses on excessive frequency of contractions rather than their duration.

Choice B rationale

Contraction frequency of more than 5 in 10 minutes defines tachysystole. This condition indicates too frequent uterine activity, which can compromise fetal oxygenation.

Choice C rationale

Contraction intensity less than 80 mm Hg doesn't define tachysystole. Tachysystole is characterized by the number of contractions, not their intensity.

Choice D rationale

Resting tone less than 18 mm Hg is not related to the definition of tachysystole. Tachysystole concerns contraction frequency, not the resting tone of the uterus between contractions. .

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