A nurse is caring for a client at the clinic.
Complete the following sentence by using the lists of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Rationale for correct choices
• Spontaneous abortion: The client is at 10 weeks gestation with vaginal bleeding, abdominal cramping, and an open cervix, which are classic findings associated with spontaneous abortion. The presence of cervical dilation indicates that pregnancy loss is actively occurring or imminent. These findings distinguish spontaneous abortion from other early pregnancy complications.
• Cervical dilation: Cervical dilation during early pregnancy is a key indicator of pregnancy loss. In spontaneous abortion, the cervix opens as products of conception begin to pass. This finding provides objective evidence that the pregnancy is not being maintained.
Rationale for incorrect choices
• Molar pregnancy: Molar pregnancy is associated with excessively high hCG levels, uterine enlargement greater than gestational age, and symptoms such as severe nausea or hyperemesis. The client’s hCG level is appropriate for gestational age and does not suggest trophoblastic overgrowth. Cervical dilation is not a defining feature of molar pregnancy.
• Ectopic pregnancy: Ectopic pregnancy typically presents with unilateral pelvic pain, possible shoulder pain, and often no cervical dilation. Vaginal bleeding may occur, but the cervix usually remains closed. Additionally, ectopic pregnancies often have lower-than-expected hCG levels.
• Lower abdominal cramping: Abdominal cramping is a common symptom in many early pregnancy complications and is not specific to spontaneous abortion. While it supports uterine activity, it does not independently confirm pregnancy loss. Cervical dilation provides stronger diagnostic evidence. Cramping alone is insufficient as the primary indicator.
• hCG levels: The client’s hCG level is within the expected range for 10 weeks gestation. Abnormally high levels would suggest molar pregnancy, while low or slowly rising levels might suggest ectopic pregnancy or nonviable gestation. In this case, hCG does not explain the acute findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, motor function, and level of cooperation is essential to determine how much assistance is needed and which repositioning techniques are safest. Stroke clients may have hemiplegia or weakness, and understanding their abilities prevents injury to both the client and the nurse.
B. Reposition the client without the use of assistive devices: Using assistive devices such as slide sheets, gait belts, or mechanical lifts is recommended for clients with limited mobility to reduce the risk of musculoskeletal injury. Repositioning without them increases the likelihood of strain or falls.
C. Discuss the client's preferences for determining a repositioning schedule: While client preferences can enhance comfort and adherence, safety and prevention of complications such as pressure injuries take priority. Scheduling should follow clinical guidelines rather than preference alone.
D. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a fall hazard or limit safe access for the nurse during repositioning. Typically, one side rail may be raised as needed, while the other is lowered to allow safe maneuvering.
Correct Answer is A,B,C,D
Explanation
A. Transport the client to another area of the nursing unit: The first priority during a fire is rescue, ensuring the safety of any individuals in immediate danger. Removing the client from the room prevents exposure to smoke, heat, and flames.
B. Activate the facility's fire alarm system: After ensuring the client’s safety, the nurse must alert others and initiate the facility’s emergency response. Early notification facilitates rapid evacuation and mobilization of fire response teams.
C. Close all nearby windows and doors: Closing doors and windows helps contain the fire, limits oxygen supply to the flames, and reduces the spread of smoke and fire to other areas of the unit.
D. Use the unit's fire extinguisher to attempt to put out the fire: Once people are safe and the alarm is activated, the nurse may attempt to extinguish a small, controllable fire using the appropriate fire extinguisher, following the PASS technique (Pull, Aim, Squeeze, Sweep).
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