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 C
Explanation
A. Ensure that the restraints are snug against the client's wrists: Restraints should be snug enough to prevent injury but not so tight as to impair circulation. However, this does not address the safety concern related to the type of knot used.
B. Move the ties so the restraints are secured to the side rails: Restraints should never be tied to the side rails because this can cause injury if the rail moves or the client attempts to climb over it.
C. Ensure that the knot can be quickly released: Using a quick-release knot, such as a half bow or slip knot, is essential to ensure the nurse can rapidly remove the restraints in an emergency, such as sudden respiratory distress or circulatory compromise.
D. Tie the knot with a double turn or square knot: Square knots are secure but not quick to release. In contrast, safety guidelines recommend quick-release knots for client restraints to allow for prompt intervention.
Correct Answer is A
Explanation
A. Maintain the client on bedrest: The client’s symptoms are consistent with deep vein thrombosis (DVT). Bedrest with limited movement prevents dislodgment of the clot, which could otherwise travel to the lungs and cause a pulmonary embolism. This is the safest initial intervention while anticoagulation is being started.
B. Administer the client's routine daily aspirin: Aspirin has antiplatelet effects but is not the treatment of choice for acute DVT. Starting aspirin with heparin therapy is not recommended, as it increases the risk of bleeding without additional therapeutic benefit.
C. Encourage a diet high in iron and ascorbic acid: While iron and vitamin C support red blood cell production, this dietary intervention does not address the acute management of a thrombus. It may be useful in anemia prevention but is not a priority here.
D. Encourage the client to dangle the legs frequently: Dangling the legs promotes venous stasis and may worsen the clot or increase the risk of embolization. Clients with DVT should avoid activities that increase venous pooling until cleared by the healthcare provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
                        
                            
