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 C
Explanation
Choice A rationale
The hemoglobin level of 11.6 g/dL is within the normal range for a pregnant woman. While placenta previa requires monitoring, it is not immediately life-threatening.
Choice B rationale
Type 2 diabetes mellitus requires regular monitoring and management, but a single fasting blood glucose level does not indicate an immediate emergency unless it is extremely high or low.
Choice C rationale
Partial placental abruption can lead to significant complications for both the mother and fetus, including hemorrhage and fetal distress, making it the priority for immediate assessment.
Choice D rationale
An Rh-negative status and a recent cerclage placement are important for ongoing monitoring but do not present an immediate life-threatening condition that demands the first assessment.
Correct Answer is D
Explanation
Choice A rationale
Numbness in the toes and heel might suggest nerve involvement but is not a typical sign of deep vein thrombosis (DVT), which involves the veins, not nerves.
Choice B rationale
Pain relieved by dorsiflexion (positive Homan's sign) is not reliable for diagnosing DVT. This symptom is outdated and not considered a definitive sign.
Choice C rationale
Spider-like and purple veins suggest superficial varicose veins, not deep vein thrombosis, which affects deeper veins and presents differently.
Choice D rationale
Swelling, redness, and warmth in the calf are classic signs of DVT due to the inflammation and obstruction of deep veins. These symptoms should prompt immediate medical evaluation and intervention. .