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
If a nurse notes that a client’s blood pressure is 60/50 mm Hg two hours after giving birth, the first action should be to evaluate the firmness of the uterus. This is because a soft or “boggy” uterus could indicate uterine atony, a condition where the uterus fails to contract after delivery, leading to excessive bleeding and a drop in blood pressure.
Choice B rationale
Administering oxytocin infusion can help stimulate uterine contractions and control postpartum bleeding. However, it is not the first action to take. The nurse should first assess the firmness of the uterus.
Choice C rationale
Obtaining a type and crossmatch is important if a blood transfusion is required. However, this is not the first action. The nurse should first assess the firmness of the uterus.
Choice D rationale
Initiating oxygen therapy can help ensure adequate oxygen supply to the tissues, but it is not the first action. The nurse should first assess the firmness of the uterus.
Correct Answer is D
Explanation
Choice A rationale
Gravida 4 Para 3 at 33 weeks of gestation is not an alarming finding. It simply indicates that the woman is pregnant for the fourth time and has had three previous deliveries. This is a normal part of the woman’s obstetric history and does not need to be reported to the provider.
Choice B rationale
Allergies, such as a sulfa allergy, are important to note in the patient’s medical history. However, unless the patient is being prescribed a medication that she is allergic to, this information does not need to be urgently reported to the provider.
Choice C rationale
A height of 165 cm (66 in), weight of 82 kg (180 lb), and BMI of 30.6 are all within normal ranges for a pregnant woman. These measurements are part of routine prenatal care and do not need to be urgently reported to the provider.
Choice D rationale
A weight gain of 32 kg (7 lb) over the last 2 weeks is concerning. Rapid weight gain can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. This should be reported to the provider immediately.
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