A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client’s medical records.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Choice A rationale

Quickening is the sensation of fetal movement by the pregnant woman. It usually occurs between 16 and 20 weeks of gestation.

Choice B rationale

Hegar’s sign is a probable sign of pregnancy that is characterized by the compressibility and softening of the cervical isthmus, which is the portion of the cervix between the uterus and the vaginal portion of the cervix. This sign typically presents between the fourth and sixth week of pregnancy. Therefore, if the nurse identifies a probable sign indicating the softening of the lower uterine segment, it is likely that the nurse has observed Hegar’s sign.

Choice C rationale

Braxton Hicks contractions are intermittent uterine contractions that occur during pregnancy. They are not a sign of labor and do not lead to cervical dilation or effacement. Therefore, they would not indicate the softening of the lower uterine segment.

Choice D rationale

Ballottement is a technique of palpating a floating structure by bouncing it and feeling it rebound. In the context of pregnancy, it refers to the movement of the fetus when the uterus is tapped during a pelvic examination. This does not indicate the softening of the lower uterine segment.

Choice A rationale

While an elevated WBC count can indicate an infection, it is not the most important symptom to monitor in a patient with idiopathic thrombocytopenic purpura (ITP). ITP is primarily a platelet disorder, and while infection can trigger or exacerbate the condition, an elevated WBC count is not a direct symptom of ITP78.

Choice B rationale

Fever can be a sign of infection, which can trigger or exacerbate ITP. However, it is not the most important symptom to monitor in a patient with ITP78.

Choice C rationale

Ecchymosis, or bruising, is a key symptom of ITP. Because ITP involves a decrease in platelets, which are necessary for clotting, patients with this condition are prone to bruising and bleeding. Therefore, monitoring for ecchymosis is crucial.

Choice D rationale

Fatigue can be a symptom of ITP, but it is not the most important symptom to monitor. While fatigue can impact a patient’s quality of life, it does not directly indicate the severity of the condition.