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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While the fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum, it is not the priority in this case. The fundus, which is the top part of the uterus, typically descends at a rate of approximately one fingerbreadth (or one cm) per day, and by the 12th postpartum day, it should no longer be palpable.
Choice B rationale
A saturated perineal pad in 30 minutes is a sign of excessive bleeding, also known as postpartum hemorrhage. This is a serious condition that can lead to shock and other complications if not treated promptly. Therefore, this finding should be prioritized by the nurse.
Choice C rationale
Approximated edges of an episiotomy are a normal finding in the postpartum period. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery. After delivery, the episiotomy is sutured and should heal without complications with proper care. However, this is not the priority finding in this scenario.
Choice D rationale
Deep tendon reflexes 4+ could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. However, since the client is already 4 hours postpartum, this is less likely to be the priority.
Correct Answer is D
Explanation
Choice A rationale
Swaddling a newborn can provide comfort and help soothe them. However, it is not a specific treatment for a Neonatal Abstinence Scoring System (NAS) score of 201.
Choice B rationale
Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. It is not typically administered for NAS unless the newborn is experiencing life-threatening respiratory depression due to opioid exposure. Moreover, it is not specifically indicated for NAS scores greater than 241.
Choice C rationale
Continuing NAS scoring as prescribed is important for monitoring the newborn’s condition. However, a score of 20 indicates significant withdrawal symptoms, which may require more than just monitoring.
Choice D rationale
Administering oral morphine is a common treatment for NAS. Morphine, an opioid medication, is used to manage withdrawal symptoms in newborns with NAS. The goal is to control symptoms and then gradually wean the newborn off the medication.
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