A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?
Increase in pulse and fetal rate reactivity.
Pain in lower quadrant and oliguria.
Mild discomfort and elevated blood pressure.
Sharp fundal pain and uterine tenderness.
The Correct Answer is D
A. Increase in pulse and fetal rate reactivity: While changes in maternal pulse and fetal heart rate can indicate stress or early compromise, these findings alone do not specifically indicate acute maternal hemorrhage or uterine injury that requires immediate intervention.
B. Pain in lower quadrant and oliguria: These signs suggest possible urinary retention or renal compromise but are not the most urgent indicators of acute obstetric bleeding during labor.
C. Mild discomfort and elevated blood pressure: Mild discomfort and hypertension may reflect preeclampsia but do not specifically signal active hemorrhage requiring immediate reporting.
D. Sharp fundal pain and uterine tenderness: These findings are indicative of uterine rupture or abruption, both of which are obstetric emergencies. Profuse vaginal bleeding with uterine tenderness requires immediate notification of the healthcare provider to prevent maternal and fetal morbidity or
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sugar cookies: Sugar cookies are low in fat and not highly acidic, making them less likely to trigger reflux. This choice demonstrates understanding of dietary restrictions because it avoids common GERD triggers such as high-fat, spicy, or acidic foods.
B. Pizza: Pizza is high in fat, contains tomato sauce, and often includes spices—all of which can increase gastric acid secretion and exacerbate reflux symptoms. This food is not an appropriate choice for a child with GERD.
C. Tacos: Tacos typically contain seasoned meat, spices, and fatty ingredients that are known to aggravate reflux. The combination of fat and spice makes them unsuitable for someone managing GERD symptoms.
D. Chocolate milkshake: Chocolate and high-fat dairy products can lower esophageal sphincter tone and delay gastric emptying, both of which contribute to worsening reflux. This makes it an inappropriate snack option.
Correct Answer is ["B","C"]
Explanation
A. Reorient the client while performing assessment: Reorienting a client with acute dementia during periods of distress can increase confusion and agitation. Forcing orientation is often counterproductive and may escalate anxiety.
B. Lower the lighting in the client's room: Reducing harsh lighting can help decrease overstimulation and agitation, creating a calmer environment for a client experiencing acute confusion or distress.
C. Switch to a familiar topic after acknowledging client's feelings: Validating the client’s emotions and then gently redirecting to familiar topics can reduce anxiety, provide comfort, and improve cooperation without causing confrontation.
D. Remind the client that his spouse is deceased: Confronting the client with reality in a distressed state can increase agitation, fear, and confusion. Reality orientation should be approached cautiously, if at all, during acute episodes.
E. Explain the rehabilitation regimen to the client: While education about care is generally important, a client in acute dementia may not be able to process detailed explanations. This intervention does not address immediate emotional distress or safety.
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