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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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Correct Answer is B

Explanation

Choice A rationale

Administering oxytocin during shoulder dystocia can exacerbate the problem by increasing uterine contractions, making it harder to deliver the baby's shoulder.

Choice B rationale

Flexing the client's thighs sharply toward her abdomen, known as the McRoberts maneuver, helps to widen the pelvis and can often resolve shoulder dystocia by changing the angle of the pelvic bones.

Choice C rationale

While applying oxygen is a standard practice to improve maternal and fetal oxygenation, it does not specifically address shoulder dystocia and is not a primary intervention.

Choice D rationale

Applying downward pressure on the fundus is contraindicated as it can worsen shoulder dystocia by further impacting the shoulder against the pelvic bone.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Massaging the fundus helps to stimulate uterine contractions, reducing bleeding and promoting firmness in the uterus. Ensuring IV access is critical for administering medications and

fluids quickly.

Choice B rationale

Methylergonovine (Methergine) is used to prevent and control postpartum hemorrhage by promoting uterine contractions. Oxytocin bolus also helps stimulate contractions, preventing

further blood loss.

Choice C rationale

Carboprost tromethamine (Hemabate) is another uterotonic agent used to control severe postpartum hemorrhage by causing uterine contractions. Its use depends on the patient's

response to other treatments.

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