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?

Uterine rupture.

Placental abruption.

Placenta previa.

Amniotic fluid embolus.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Uterine rupture typically presents with intense, constant abdominal pain and signs of shock. However, the absence of visible bleeding in the abdominal cavity makes this choice less likely in this case.

Choice B rationale:

Placental abruption involves the premature separation of the placenta from the uterine wall before delivery. The sudden, severe abdominal pain, moderate vaginal bleeding, persistent uterine contractions, and signs of hypovolemic shock (low blood pressure, rigid abdomen) are indicative of placental abruption. This condition requires immediate medical intervention due to the risk of fetal and maternal compromise.

Choice C rationale:

Placenta previa occurs when the placenta partially or completely covers the cervical opening. It typically presents with painless, bright red vaginal bleeding. The severe abdominal pain described in the scenario is inconsistent with placenta previa.

Choice D rationale:

Amniotic fluid embolus is a rare and life-threatening condition in which amniotic fluid enters the maternal bloodstream, causing an allergic reaction. It can lead to sudden cardiovascular collapse. Although it can cause respiratory distress and hypotension, it does not usually present with severe abdominal pain or uterine contractions.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Correct. Difficulty performing ADLs such as dressing, grooming, bathing, or feeding may indicate that the client has impaired motor function, sensory perception, or cognitive ability due to the stroke, which can affect their independence and quality of life. Occupational therapy can help the client regain or adapt their skills and abilities for daily living.
B. Incorrect. Inability to swallow clear liquids may indicate that the client has dysphagia or impaired swallowing function due to the stroke, which can increase their risk of aspiration and malnutrition. Speech therapy can help the client improve their swallowing function and provide recommendations for safe oral intake.
C. Incorrect. Elevated blood glucose levels may indicate that the client has diabetes mellitus or impaired glucose metabolism due to the stroke, which can affect their healing and recovery process and increase their risk of complications such as infection or hyperglycemia/hypoglycemia episodes. Diabetes education and management can help the client control their blood glucose levels and prevent adverse outcomes.
D. Incorrect. Unsteady gait when ambulating may indicate that the client has impaired balance, coordination, or muscle strength due to the stroke, which can affect their mobility and safety and increase their risk of falls or injuries. Physical therapy can help the client improve their gait and mobility and provide assistive devices if needed.

A. Shellfish. B. Egg. C. Gelatin. D. Milk.

Correct Answer is B

Explanation

Choice A rationale:

Shellfish allergies are not a contraindication to receiving the influenza vaccine. The vaccine contains no shellfish-derived ingredients.

Choice B rationale:

Egg allergies are a contraindication to receiving the influenza vaccine. Traditionally, most influenza vaccines are prepared using eggs and can provoke allergic reactions in individuals allergic to eggs. However, individuals with a mild egg allergy can often receive the vaccine under medical supervision. It is crucial to assess the severity of the egg allergy and consult with an allergist or immunologist before administering the vaccine.

Choice C rationale:

Gelatin allergies are generally not a contraindication to receiving the influenza vaccine. While some vaccines contain gelatin, it is not a component of all influenza vaccines. If the specific vaccine being administered contains gelatin, it should be avoided in individuals with a gelatin allergy.

Choice D rationale:

Milk allergies are not a contraindication to receiving the influenza vaccine. Milk or dairy products are not typically included in the influenza vaccine formulation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

Correct Answer is A

Explanation

A nurse is assessing a client for allergies prior to administering the influenza vaccine.The nurse should identify that an allergy to which of the following foods is a contraindication to receiving this vaccine?

Correct Answer is B

Explanation

A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

A nurse is teaching a client who has a new prescription for sertraline to treat depression.For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?