Author Question: The nurse is caring for a patient at 35 weeks' gestation who has been critically injured in a ... (Read 90 times)

APUS57 · **on:** Jun 27, 2018

The nurse is caring for a patient at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern?

1. Blood pressure 110/68, pulse 90.
2. Entrance wound present below the umbilicus.
3. Patient is positioned in a left lateral tilt.
4. Clear fluid is leaking from the vagina.

Question 2

The client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. What is the nurse's best response to the client?

1. Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress.
2. When your perineal body thins out, your cervix will begin to dilate much faster than it is now.
3. What did you expect? You've only had contractions for a few hours. Labor takes time.
4. The hormones that cause labor to begin are just getting to be at levels that will change your cervix.

moormoney · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

2
Rationale 1: These are normal vital signs, indicating a hemodynamically stable client.
Rationale 2: Penetrating abdominal trauma has a 5980 fetal injury rate. This fetus is at great risk for injury.
Rationale 3: Positioning the client in a lateral tilt position prevents vena cava syndrome.
Rationale 4: Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term, and would likely survive birth at this time.

Answer to Question 2

1
Explanation: 1. With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. Effacement is the taking up (or drawing up) of the internal os and the cervical canal into the uterine side walls.