A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

Hemorrhage

Edema

Infection

Jaundice

Answer and Explanation

The Correct Answer is A

Choice A reason: Hemorrhage is the most life-threatening complication of a ruptured ectopic pregnancy, as it can lead to hypovolemic shock and death. The nurse should monitor the client's vital signs, blood loss, and level of consciousness, and administer fluids and blood products as ordered.

Choice B reason: Edema is not a common sign of a ruptured ectopic pregnancy, and it is not a priority over hemorrhage. Edema may be caused by other conditions, such as heart failure, kidney disease, or venous insufficiency.

Choice C reason: Infection is a possible complication of a ruptured ectopic pregnancy, but it is not as urgent as hemorrhage. Infection may manifest as fever, chills, malaise, or foul-smelling vaginal discharge. The nurse should administer antibiotics as ordered and monitor the client's temperature and white blood cell count.

Choice D reason: Jaundice is not a typical symptom of a ruptured ectopic pregnancy, and it is not a priority over hemorrhage. Jaundice may indicate liver dysfunction or hemolytic anemia, which are unrelated to ectopic pregnancy. The nurse should assess the client's skin and sclera color, and check the liver enzymes and bilirubin levels.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because this description accurately reflects one of the main functions of amniotic fluid, which is to act as a shock absorber and buffer against external forces or movements that could harm the fetus. Amniotic fluid also allows the fetus to move freely and develop its muscles and bones.

Choice B Reason: This is incorrect because this description is false. The amount of amniotic fluid changes throughout the pregnancy, depending on the stage of fetal development and other factors. The normal range of amniotic fluid volume is between 500 and 1000 mL at term. Too much or too little amniotic fluid can indicate a problem with the fetus or the placenta.

Choice C Reason: This is incorrect because this description is false. The fluid is not mostly protein, but mostly water (about 98%). The water comes from the mother's blood plasma and the fetal urine. The remaining 2% of amniotic fluid consists of various substances, such as electrolytes, hormones, enzymes, antibodies, and fetal cells. Amniotic fluid does not provide nourishment to the fetus, but rather protects it from infection and helps regulate its temperature.

Choice D Reason: This is incorrect because this description is false. Amniotic fluid does not act as a transport mechanism for oxygen and nutrients, but rather as a barrier that prevents them from reaching the fetus directly. Oxygen and nutrients are delivered to the fetus through the placenta and the umbilical cord, which are connected to the maternal blood circulation.

A. Ultrasound visualization of the fetus B. Softening of the cervix C. Positive pregnancy test D. Absence of menstruation E. Ballottement F. Auscultation of a fetal heart beat

Correct Answer is ["B","C","D","E"]

Explanation

Choice A Reason: This is incorrect because ultrasound visualization of the fetus is a positive sign of pregnancy, not a probable sign. A positive sign of pregnancy is a direct and definitive evidence of the presence of a fetus, such as fetal movement felt by the examiner or fetal heart sounds heard by a Doppler device.

Choice B Reason: This is correct because softening of the cervix, also known as Goodell's sign, is a probable sign of pregnancy. A probable sign of pregnancy is a strong indication of pregnancy based on physical changes in the reproductive organs, such as enlargement of the uterus or changes in the shape and consistency of the cervix.

Choice C Reason: This is correct because a positive pregnancy test, which detects human chorionic gonadotropin (hCG) in urine or blood, is a probable sign of pregnancy. However, it is not a conclusive sign, as hCG can also be produced by other conditions such as ectopic pregnancy, molar pregnancy, or trophoblastic tumors.

Choice D Reason: This is correct because absence of menstruation, also known as amenorrhea, is a probable sign of pregnancy. It occurs when ovulation and menstruation cease due to hormonal changes during pregnancy. However, it is not a definitive sign, as amenorrhea can also be caused by other factors such as stress, illness, or hormonal imbalances.

Choice E Reason: This is correct because ballottement, which is a rebounding of the fetus against the examiner's fingers during a pelvic examination, is a probable sign of pregnancy. It can be felt around 16 to 20 weeks of gestation.

Choice F Reason: This is incorrect because auscultation of a fetal heart beat, which can be heard by a fetoscope around 18 to 20 weeks of gestation or by a Doppler device around 10 to 12 weeks of gestation, is a positive sign of pregnancy, not a probable sign.

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A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

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Naxlex Comprehensive Predictor Exams

During a prenatal visit, a pregnant woman says, "I know the amniotic fluid is important, but can you tell me more about it?" When describing amniotic fluid to a pregnant woman, which description would the nurse most likely include?

Correct Answer is A

Explanation

A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which findings would the nurse most likely assess? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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