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. "Perhaps you think the ECT is dangerous, but I've seen it have good results." B. "You have the right to change your mind about this procedure at any time." C. "Everyone gets a little nervous about this procedure as the time for it approaches." D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you."

Correct Answer is B

Explanation

You have the right to change your mind about this procedure at any time.

Rationale:

A. "Perhaps you think the ECT is dangerous, but I've seen it have good results." This response is dismissive of the client's concerns and implies that the nurse knows better than the client.
B. "You have the right to change your mind about this procedure at any time." This response respects the client's autonomy and informs them of their rights.
C. "Everyone gets a little nervous about this procedure as the time for it approaches." This response minimizes the client's feelings and assumes that they are experiencing normal anxiety.
D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you." This response shifts the responsibility to the doctor and does not address the client's fears.

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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 caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is planning to administer packed RBCs to an older adult client who has a low hemoglobin level.Which of the following actions should the nurse plan to take?

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse not include in the change-of-shift report?

A nurse is admitting a school-age child who has bacterial meningitis.Which of the following types of isolation precautions should the nurse initiate?

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

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

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?