A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?
Abdominal pain
Hydramnios
Profuse vaginal bleeding
Elevated blood pressure
The Correct Answer is A
Choice A reason: Abdominal pain is a hallmark of ectopic pregnancy, where the embryo implants outside the uterus, often in the fallopian tube. Tissue stretching or rupture causes localized pain, driven by tubal irritation or internal bleeding, requiring urgent evaluation to prevent life-threatening hemorrhage in affected clients.
Choice B reason: Hydramnios, excessive amniotic fluid, occurs in intrauterine pregnancies, not ectopic ones, which lack a uterine gestational sac. Ectopic pregnancies cannot produce amniotic fluid, as implantation occurs outside the uterus, making hydramnios an irrelevant finding in this condition’s pathophysiology.
Choice C reason: Profuse vaginal bleeding is uncommon in ectopic pregnancy, which typically causes spotting or mild bleeding. Heavy bleeding suggests miscarriage or other conditions. Ectopic pregnancies cause internal bleeding, leading to abdominal pain, not profuse vaginal hemorrhage, a key diagnostic distinction.
Choice D reason: Elevated blood pressure is not typical in ectopic pregnancy unless complicated by pain-induced stress or shock. Internal bleeding from ectopic rupture often lowers blood pressure due to hypovolemia, making hypertension an unlikely finding compared to the expected abdominal pain presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Using gauze to cover an infant’s IV site obscures visualization, delaying detection of infiltration or infection. Transparent dressings are preferred, as infants’ small veins are prone to complications. Gauze increases risk by hiding signs like swelling, critical for early intervention in pediatric IV management.
Choice B reason: Monitoring an IV site every 8 hours is inadequate for infants, who need hourly checks due to small vein fragility and high infiltration risk. Frequent assessment detects complications like phlebitis or extravasation early, ensuring vascular integrity and preventing tissue damage in pediatric patients.
Choice C reason: Inserting an IV in the foot is less preferred, as scalp or hand veins are more accessible and stable in infants. Foot IVs risk dislodgement from movement and may impair circulation, increasing complications like tissue damage, making this a suboptimal choice for IV placement.
Choice D reason: A 24-gauge catheter is ideal for infants, as their small veins require smaller needles to minimize trauma and infiltration. This size ensures adequate fluid or medication delivery while reducing vascular damage, aligning with pediatric IV guidelines for safe and effective venous access.
Correct Answer is C
Explanation
Choice A reason: Administering atomoxetine, used for ADHD, is inappropriate for panic attacks, which require short-acting anxiolytics like benzodiazepines if medicated. This medication does not address acute anxiety and may worsen symptoms, making it incorrect and potentially harmful.
Choice B reason: Encouraging television watching may distract but does not address the acute distress of a panic attack. It lacks the calming, supportive presence needed to reduce anxiety, making it less effective and inappropriate compared to direct emotional support.
Choice C reason: Sitting with the client provides a calming presence, reducing fear and enhancing security during a panic attack. This therapeutic intervention supports emotional regulation and aligns with evidence-based anxiety management, making it the correct and most effective action.
Choice D reason: Instructing strenuous exercise during a panic attack can exacerbate symptoms like tachycardia and breathlessness, worsening anxiety. Calming techniques like deep breathing are preferred, so this action is counterproductive and potentially harmful, making it incorrect.
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