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":"C","dropdown-group-2":"A"}
Rationale for correct choices
• Spontaneous abortion: The client is presenting at 10 weeks gestation with moderate, bright red vaginal bleeding and a history of risk factors including type 1 diabetes mellitus and recurrent infections. The open cervix on examination indicates that the pregnancy may not be viable and suggests impending or ongoing miscarriage.
• Cervical dilation: Cervical dilation is a key clinical sign of spontaneous abortion, as it indicates that the body is preparing to expel the pregnancy. The presence of an open cervix in conjunction with vaginal bleeding and cramping directly supports the risk for miscarriage. Monitoring cervical changes helps the healthcare team assess the progression and urgency of intervention.
Rationale for incorrect choices
• Molar pregnancy: Molar pregnancy typically presents with markedly elevated hCG levels, larger-than-expected uterine size, and absence of a viable embryo. Although the client has an elevated hCG, the level is not excessively high, and there is no indication of vesicular tissue or characteristic ultrasound findings, making molar pregnancy unlikely.
• Ectopic pregnancy: Ectopic pregnancy generally presents with unilateral abdominal pain, shoulder pain, and sometimes hypotension or signs of internal bleeding. The client’s bleeding is bright red, moderate, and accompanied by cervical dilation, which is not typical for an ectopic pregnancy. No abdominal mass or unilateral tenderness is reported, reducing the likelihood of this diagnosis.
• Lower abdominal cramping: While cramping is a symptom associated with miscarriage, it alone is not sufficient evidence to determine the risk for spontaneous abortion. Cervical dilation is a more definitive clinical sign indicating that the miscarriage may be occurring or imminent.
• hCG levels: The client’s hCG level of 30,000 IU/L is within the expected range for 10 weeks gestation and does not specifically indicate miscarriage. Unlike cervical dilation, hCG levels alone cannot confirm the risk for spontaneous abortion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Restrict daily exercise: Clients with heart failure benefit from regular, moderate activity as tolerated to improve cardiac efficiency and prevent deconditioning. Restricting all exercise can worsen functional status and is not recommended unless specifically limited by the healthcare provider.
B. Encourage 3 large meals per day: Large meals can increase cardiac workload and exacerbate heart failure symptoms due to increased blood flow demands during digestion. Smaller, more frequent meals are preferable to reduce strain on the heart.
C. Limit dietary salt intake: Reducing sodium intake helps prevent fluid retention and edema, which can exacerbate heart failure and increase cardiac workload. Teaching clients to limit salt is a key intervention to manage decreased cardiac output and maintain stable fluid balance.
D. Obtain weight once per week: Daily weight monitoring is recommended for clients with heart failure to detect fluid retention early. Weekly weights may delay recognition of sudden fluid accumulation, increasing the risk of decompensation.
Correct Answer is D
Explanation
Rationale:
A. Instruct the client to carry the newborn in their arms when going to the nursery: Carrying a newborn to the nursery without security measures increases the risk of abduction. Infants should always be transported in a secure bassinet or by authorized staff using the hospital’s safety protocols.
B. Remove the electronic security sensor when the newborn is in the client's room: The electronic security sensor is essential for monitoring the newborn’s location within the hospital. Removing it defeats the purpose of the abduction prevention system and is unsafe.
C. Apply identification bands after the newborn's first bath: Identification bands should be applied immediately after birth to ensure accurate identification from the start. Waiting until after the first bath delays verification and increases risk for misidentification or abduction.
D. Discourage family from posting photos of the newborn on social media: Sharing identifiable information or images online can inadvertently alert potential abductors to the newborn’s presence. Families should be advised to limit social media exposure until the infant’s safety can be ensured.
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