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:

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.

A. Organizing the work environment B. Delegating assigned tasks appropriately C. Making a list of activities to complete D. Rewarding yourself for accomplishing goals

Correct Answer is C

Explanation

- A. Incorrect. Organizing the work environment is an important step of the time management process, but it is not the priority. The nurse manager should first identify the activities that need to be done before organizing them.

- B. Incorrect. Delegating assigned tasks appropriately is an important step of the time management process, but it is not the priority. The nurse manager should first determine which tasks can be delegated and which ones require their direct involvement before assigning them to others.

- C. Correct. Making a list of activities to complete is the priority step of the time management process, as it helps the nurse manager to identify and prioritize their goals and responsibilities.

- D. Incorrect. Rewarding yourself for accomplishing goals is an important step of the time management process, but it is not the priority. The nurse manager should first complete the tasks that are essential and urgent before rewarding themselves for their achievements.

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Naxlex Comprehensive Predictor Exams

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 nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?

Correct Answer is C

Explanation

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

A client on an acute mental health unit states to a nurse, "Tie a bow.Row the boat.Now I know.Whoa! I see you, yo." The nurse should document that the client is exhibiting which of the following speech alterations?

A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

A community health nurse is planning an educational program on Lyme disease for the general public.Which of the following statements should the nurse include in the program?

A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to hand-hygiene protocols.Which of the following steps should the task force take first?

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?