A client at 38-weeks gestation reports experiencing severe abdominal pain.
Upon palpation, the nurse notes that the abdomen is rigid.
How should the nurse document the findings?
Placenta previa.
Oligohydramnios.
Abruptio placenta.
Chorioamnionitis.
The Correct Answer is C
Choice A rationale
Placenta previa is a condition where the placenta covers the cervix, which can cause painless bleeding, not severe abdominal pain.
Choice B rationale
Oligohydramnios refers to a condition where there is less amniotic fluid around the baby in the womb. It does not typically cause severe abdominal pain.
Choice C rationale
Abruptio placenta is a serious condition where the placenta detaches from the uterus before the baby is born. It can cause severe abdominal pain and a rigid abdomen, which matches the symptoms described.
Choice D rationale
Chorioamnionitis is an infection of the membranes surrounding the fetus and the amniotic fluid. It typically presents with fever and increased heart rate, not necessarily severe abdominal pain and a rigid abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F","G","H"]
Explanation
Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.
Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
Correct Answer is C
Explanation
Choice A rationale
While assessing for bladder distention is important in general urinary assessment, it is not directly related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice B rationale
Listening for bowel sounds is a part of the general abdominal assessment. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice C rationale
Documenting the observation is the correct action. The nurse has observed that the infant voids a urinary stream from the ventral surface of the penis. This could indicate a condition such as hypospadias, where the urethral opening is on the underside of the penis. This is an important finding that should be documented and reported.
Choice D rationale
Checking the scrotum for testicular descent is part of the general assessment of the male genitalia. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
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