Examkin

Question

Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

The charge nurse on a maternity unit is reviewing assessment data and ongoing care for several clients. Which of the following clinical findings or situations require the nurse's immediate intervention? Select all that apply.

  1. A client in active labor whose electronic fetal monitor tracing displays recurrent late decelerations with absent variability.Answer
  2. B
    A client in the active phase of labor with fetal heart rate early decelerations that mirror the pattern of uterine contractions.
  3. A client who is two hours postpartum exhibiting a heart rate of 118 beats per minute, a narrowing pulse pressure, and a boggy uterus.Answer
  4. D
    A stable client who is 24 hours postpartum being assisted with ambulation and perineal care by an unlicensed assistive personnel (UAP).
  5. A client at 34 weeks of gestation who reports a sudden onset of severe abdominal pain and has a rigid, board-like abdomen on palpation.Answer
  6. F
    A client at 38 weeks of gestation reporting irregular, mild uterine cramping that completely resolves after resting and drinking water.

Answer

The situations requiring immediate intervention are the client with recurrent late decelerations, the postpartum client showing early signs of hypovolemic shock, and the antepartum client exhibiting signs of placental abruption.
Situations requiring immediate intervention involve life-threatening conditions or severe physiological compromise. Recurrent late decelerations with absent variability indicate severe uteroplacental insufficiency and fetal hypoxia. A boggy uterus with tachycardia and a narrowing pulse pressure are classic early signs of postpartum hemorrhage and compensatory hypovolemic shock. A rigid, board-like abdomen with severe pain strongly suggests placental abruption, a critical emergency requiring immediate stabilization and delivery.

Step-by-Step Solution

1
Evaluate the fetal heart rate (FHR) tracing descriptions.
Identified that late decelerations with absent variability indicate fetal distress (requires intervention), whereas early decelerations are benign (no intervention).
Accurate interpretation of FHR patterns is critical to prioritize intrapartum care and distinguish normal physiological responses from utero-placental insufficiency.
2
Analyze the postpartum assessment data.
Recognized that a boggy uterus with tachycardia and narrowing pulse pressure signals impending shock (requires intervention).
Early identification of hemorrhage and compensatory shock mechanisms allows for life-saving interventions before cardiovascular collapse occurs.
3
Differentiate between normal antepartum findings and obstetric emergencies.
Determined that irregular cramps resolving with water are normal Braxton Hicks contractions, while a rigid, board-like abdomen indicates a placental abruption (requires intervention).
Nurses must rapidly triage pregnancy complications to ensure maternal and fetal safety, preventing unnecessary interventions for normal false labor.
4
Assess the appropriateness of the delegated tasks on the unit.
Confirmed that a UAP assisting a stable 24-hour postpartum client with ambulation is appropriate (no intervention needed).
Understanding scope of practice ensures safe delegation and allows the registered nurse to focus on critical or unstable clients.

Key Concept

Prioritization of Obstetric Emergencies and Fetal Distress
Rate this question

Topics

Ante/Intra/Postpartum and Newborn Care

More questions from this topic