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 their abdomen is rigid. The nurse should identify these findings as indicating which of the following complications?
Placental abruption
Uterine rupture
Placenta previa
Amniotic fluid embolus
The Correct Answer is A
A. Placental abruption: Placental abruption is characterized by the premature separation of the placenta from the uterine wall before delivery of the fetus. Sudden, severe abdominal pain, moderate to severe vaginal bleeding, persistent uterine contractions, and uterine rigidity are classic signs and symptoms of placental abruption. Hypotension may occur due to hemorrhage, leading to decreased perfusion to vital organs.
B. Uterine rupture: Uterine rupture involves a tear in the uterine wall, which can lead to severe abdominal pain, vaginal bleeding, and signs of shock. However, uterine rupture typically occurs during labor or delivery, particularly in women with a history of uterine surgery or trauma.
C. Placenta previa: Placenta previa is characterized by the implantation of the placenta over or near the internal cervical os. It can cause painless vaginal bleeding in the third trimester, particularly after 20 weeks of gestation. However, it is not typically associated with severe abdominal pain or uterine rigidity.
D. Amniotic fluid embolus: An amniotic fluid embolus occurs when amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, leading to a potentially life-threatening reaction. Symptoms may include sudden dyspnea, hypotension, cardiovascular collapse, and disseminated intravascular coagulation (DIC). While it can cause severe complications, the symptoms described in the scenario are more consistent with placental abruption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Iron: Iron supplements are not typically contraindicated with spironolactone use. Spironolactone is a potassium-sparing diuretic and may lead to hyperkalemia, but iron supplements are not directly associated with this risk.
B. Calcium: Calcium supplements are not typically contraindicated with spironolactone use. However, calcium supplements should be taken separately from spironolactone to avoid potential interactions that may reduce the absorption of both medications.
C. Magnesium: Magnesium supplements are not typically contraindicated with spironolactone use. However, magnesium-containing antacids should be used with caution due to the potential for increased magnesium levels in the body, especially in individuals with impaired renal function.
D. Potassium: Spironolactone is a potassium-sparing diuretic, meaning it helps retain potassium in the body. Concurrent use of potassium supplements or foods high in potassium can lead to hyperkalemia when combined with spironolactone. Therefore, the client should avoid potassium supplements while taking spironolactone to prevent this risk.
Correct Answer is A
Explanation
Observe the client for 1 hr after meals: This action is appropriate during the first week of care for a client with anorexia nervosa to monitor for signs of refeeding syndrome, such as electrolyte imbalances or hypoglycemia, which can occur after meals. Continuous observation allows for prompt intervention if complications arise.
B. Obtain the client's vital signs every other day: Vital signs should be monitored more frequently, especially during the initial phase of care, to assess for any physiological changes associated with refeeding or complications of anorexia nervosa.
C. Weigh the client every 48 hr: Weighing the client every 48 hours may not provide sufficient monitoring during the first week, as weight changes can occur rapidly in clients with anorexia nervosa. Daily weights are typically recommended during the initial phase of treatment.
D. Allow the client to eat meals in their room: Allowing the client to eat meals in their room may contribute to further isolation and avoidance of social interaction, which can exacerbate symptoms of anorexia nervosa. It's important to encourage meal consumption in a supportive environment, such as a dining area, where the client can receive encouragement and monitoring from staff and peers.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
