A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contractions. The client's blood pressure is 88/50 mm Hg and her abdomen is rigid. The nurse should identify these findings as Indicating which of the following complications?
Placental abruption
Amniotic fluid embolus
Placenta previa
Uterine rupture
The Correct Answer is A
A. Placental abruption – This is the correct answer because placental abruption occurs when the placenta detaches prematurely from the uterine wall, leading to severe abdominal pain, vaginal bleeding, uterine rigidity, and signs of hypovolemic shock (low blood pressure). The hallmark sign is a painful, rigid abdomen with contractions.
B. Amniotic fluid embolus – This condition presents with sudden respiratory distress, hypotension, and disseminated intravascular coagulation (DIC), but it does not typically cause uterine rigidity or persistent contractions.
C. Placenta previa – Placenta previa typically presents with painless vaginal bleeding rather than severe abdominal pain and a rigid uterus.
D. Uterine rupture – Uterine rupture is usually associated with a history of uterine surgery (e.g., previous cesarean section). It presents with sudden, severe pain followed by cessation of contractions, not persistent contractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Use clean technique for invasive procedures. – Incorrect. Sterile technique, not clean technique, is required to prevent infection in neutropenic clients.
B. Allow healthy children to visit. – Incorrect. Clients with neutropenia should avoid exposure to children due to the risk of infections.
C. Monitor the client's temperature every 4 hr. – Correct. Fever can indicate infection, which is life-threatening for neutropenic clients. Early detection is crucial.
D. Make sure the client's room is cleaned every 2 days. – Incorrect. The room should be cleaned daily to reduce infection risk.
Correct Answer is D
Explanation
A. Place the client in Trendelenburg position during the procedure – Incorrect, as amniocentesis is typically performed with the client in a supine position.
B. Instruct the client to maintain a full bladder for the procedure – This is required for an early pregnancy amniocentesis (before 20 weeks), but for later procedures, the bladder should be empty.
C. Administer a tocolytic 30 min before the procedure – Not routinely necessary unless the client is at risk for preterm labor.
D. Monitor the fetal heart rate throughout the procedure – Correct, as amniocentesis carries a risk of fetal distress, and continuous monitoring ensures immediate detection of complications.
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