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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Naxlex Comprehensive Predictor Exams

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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. Perform ADLs for the client to promote rest B. Allow for frequent rest periods throughout the day C. Use heat to reduce joint inflammation D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain

Correct Answer is B

Explanation

Allow for frequent rest periods throughout the day.

A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain. - D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.

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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 planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?

A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

A nurse is caring for four children in an emergency department.Which of the following clients should the nurse assess first?

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

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 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 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?