A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant.
The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?
Chadwick’s sign.
Chvostek’s sign.
Goodell’s sign.
Cullen’s sign.
The Correct Answer is D
Choice A rationale
Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. This sign is commonly seen in early pregnancy, but it does not indicate the presence of blood in the peritoneum.
Choice B rationale
Chvostek’s sign is a clinical sign of existing nerve hyperexcitability seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. This sign is not related to a ruptured ectopic pregnancy.
Choice C rationale
Goodell’s sign is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascular softening is seen in early pregnancy. It does not indicate the presence of blood in the peritoneum.
Choice D rationale
Cullen’s sign is the appearance of bruising in the skin around the umbilicus. It occurs when there is blood in the peritoneum, or intra-abdominal bleeding. In the case of a suspected ruptured ectopic pregnancy, Cullen’s sign would indicate the presence of blood in the peritoneum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Chorioamnionitis. Based on the information provided, the patient is at risk of developing chorioamnionitis, which is an infection of the membranes surrounding the fetus.
Choice B rationale
Preeclampsia. There is no information provided that would indicate the patient is at risk of developing preeclampsia.
Choice C rationale
Gestational diabetes. There is no information provided that would indicate the patient is at risk of developing gestational diabetes.
Choice D rationale
Preterm labor. There is no information provided that would indicate the patient is at risk of developing preterm labor.
Correct Answer is A
Explanation
Choice A rationale
The recommended time for rubella immunization for a woman who does not have immunity is shortly after giving birth. The MMR vaccine, which protects against measles, mumps, and rubella, is a live virus vaccine and is not recommended during pregnancy.
Choice B rationale
While it’s important for a woman to have immunity to rubella before her next pregnancy, waiting until her next attempt to get pregnant to get the vaccine could potentially leave her unprotected if she becomes pregnant sooner than planned.
Choice C rationale
The MMR vaccine is not recommended during pregnancy, including in the third trimester.
Choice D rationale
The MMR vaccine is not recommended during pregnancy, including in the second trimester.
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