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
Blood pressure of 160/110 indicates severe preeclampsia and warrants immediate intervention to prevent complications. Stopping oxytocin is part of the management of severe
preeclampsia to avoid exacerbating the condition.
Choice B rationale
Frequency of contractions every 3 minutes is within the normal range during labor induction and does not warrant stopping the infusion unless there are other concerns.
Choice C rationale
A fetal heart rate of 155 bpm with early decelerations may require close monitoring but does not necessarily warrant stopping the oxytocin infusion. Early decelerations are typically a
normal physiological response.
Choice D rationale
Frequency of contractions every 3 minutes is expected during active labor and is generally not a cause to stop the oxytocin infusion. The nurse should continue to monitor the labor
progression closely.
Correct Answer is A
Explanation
Choice A rationale
Vaginal hematomas are usually associated with severe pain due to the accumulation of blood in the tissues.
Choice B rationale
Bleeding might be visible, but hematomas often cause internal accumulation, not external bleeding.
Choice C rationale
Warmth is not typically associated with hematomas; instead, pain and swelling are more common.
Choice D rationale
Redness may occur, but pain is the most consistent symptom.