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
While maternal lacerations are a risk during childbirth, they are not the greatest risk in cases of fetal dystocia. The focus is primarily on fetal wellbeing.
Choice B rationale
Fetal injury such as bruising can occur with dystocia, but the primary concern is the potential for severe, life-threatening complications.
Choice C rationale
Neonatal asphyxia related to prolonged labor is the greatest risk with fetal dystocia. Prolonged labor can lead to decreased oxygen supply to the fetus, causing asphyxia and
potential brain injury.
Choice D rationale
Increased consideration for a cesarean delivery is a possible outcome of fetal dystocia, but it is a management decision rather than a direct risk to the baby’s immediate health.
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.