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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Correct Answer is B

Explanation

Choice A rationale:

A client who had blood drawn from the right antecubital area 1 hour ago does not require blood pressure measurement from the left arm. Blood drawing from one arm does not affect the accuracy of blood pressure measurement in the opposite arm.

Choice B rationale:

A client who has a right peripherally inserted central catheter (PICC) line should have blood pressure measured from the opposite arm to avoid disrupting the PICC line.

Choice C rationale:

A client who had dialysis and is using an arteriovenous shunt in the left lower forearm should have blood pressure measured from the opposite arm. Using the arm with an arteriovenous shunt for blood pressure measurement can lead to inaccurate readings and potentially damage the shunt, disrupting the client's dialysis treatment.

Choice D rationale:

A client who had a right hemisphere stroke does not necessarily require blood pressure measurement from the left arm. Stroke location does not impact the choice of the arm for blood pressure measurement; other factors, such as vascular access devices or medical procedures, are more relevant in this context.

A. Initiate IV access on the palmar side of the client's wrist. B. Insert a larger gauge IV catheter to prevent phlebitis. C. Choose the client's dominant arm for IV access whenever possible. D. Select a site proximal to previous venipuncture sites.

Correct Answer is D

Explanation

Choice A rationale:

Initiating IV access on the palmar side of the client's wrist is not recommended. This area has many delicate structures and is prone to complications such as nerve damage. Choosing a safer, larger vein proximal to the wrist is a better practice.

Choice B rationale:

Inserting a larger gauge IV catheter is not necessary unless the client's condition or prescribed therapy specifically requires it. Using an unnecessarily large catheter can cause discomfort and increase the risk of complications, such as phlebitis.

Choice C rationale:

Choosing the client's dominant arm for IV access whenever possible is not a universally appropriate guideline. The choice of the arm should depend on the condition of the veins and the individual patient's circumstances. The nurse should assess both arms and choose the one with the most suitable and accessible veins.

Choice D rationale:

Selecting a site proximal to previous venipuncture sites is the correct action. Repeated venipuncture in the same area can cause phlebitis and compromise the integrity of the veins. Selecting a new site proximal to previous punctures helps to preserve vein health and reduce the risk of complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

Correct Answer is B

Explanation

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A nurse is caring for a client who is in the latent phase of labor and reports severe back pain.The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station.Which of the following interventions should the nurse implement?

A nurse is caring for a 3-year-old toddler who has dehydration.Which of the following findings should the nurse report to the provider?

A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy.Which of the following instructions should the nurse include in the teaching?

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia.Which of the following actions should the nurse plan to take?

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?