A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?
Bradycardia
Abdominal pain
Hypertension
Hydramnios
The Correct Answer is B
Rationale:
A. Bradycardia: Ectopic pregnancy does not typically cause bradycardia. If cardiovascular changes occur, tachycardia is more common due to pain, blood loss, or hypovolemic shock in the event of rupture.
B. Abdominal pain: Abdominal or pelvic pain is a hallmark sign of ectopic pregnancy. Pain may be localized to one side, often corresponding to the site of implantation, and can become severe if tubal rupture occurs.
C. Hypertension: Hypertension is not associated with ectopic pregnancy. Blood pressure may decrease if significant internal bleeding occurs, potentially leading to hypotensive shock.
D. Hydramnios: Hydramnios (excess amniotic fluid) occurs in certain intrauterine complications but is not a feature of ectopic pregnancy, as the gestation occurs outside the uterine cavity.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A financial power of attorney manages financial affairs, not medical decisions. Health care decisions are instead guided by a health care proxy or durable power of attorney for health care, as outlined in the client’s advance directives.
B. The Patient Self-Determination Act upholds the client’s autonomy by allowing them to accept or refuse medical or life-sustaining treatment. This includes the right to decline care, even if such refusal may lead to death, ensuring that personal values and wishes guide end-of-life care.
C. Advance directives can be revised or revoked by the client at any time, regardless of notarization, as long as the client remains mentally competent. The document reflects current wishes and is not legally binding indefinitely.
D. Family members cannot alter a legally valid advance directive. The document represents the client’s own decisions, and only the client can modify or revoke it while competent to do so.
Correct Answer is D
Explanation
Rationale:
A. Administer betamethasone to the client: Betamethasone is given to promote fetal lung maturity in preterm labor, typically before 34 weeks of gestation. At 37 weeks, the fetus is considered term, so corticosteroids are not indicated.
B. Administer magnesium sulfate to the client: Magnesium sulfate is used for neuroprotection in preterm labor or for seizure prophylaxis in preeclampsia. Since this client is at term without preeclampsia, magnesium sulfate is not indicated.
C. Monitor fetal heart rate every 4 hr: Continuous or frequent fetal heart rate monitoring is recommended after spontaneous rupture of membranes to detect signs of fetal distress or infection. Monitoring only every 4 hours is insufficient.
D. Monitor the client's temperature every 2 hr: Maternal infection, such as chorioamnionitis, is a significant risk after spontaneous rupture of membranes. Monitoring the client’s temperature every 2 hours allows early detection of infection and timely intervention.
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