Exhibits
The client is at risk of developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Rationale for Correct Choices:
Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.
Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.
Rationale for Incorrect Choices:
Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.
Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.
Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.
Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "An incident report has been completed and sent to risk management." Incident reports are used for internal facility documentation and quality improvement but should not be mentioned in the medical record. Including this information could make the report discoverable in legal proceedings, which is why it should remain separate from the client’s medical documentation.
B. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame without objective evidence and does not follow factual documentation principles. Medical records should include observable data, client statements, and assessments rather than subjective conclusions or assumptions about the cause of the fall.
C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'" Including the client's direct statement ensures accurate, objective documentation. It provides firsthand information about the incident without making assumptions or assigning blame. Client statements should always be documented using quotation marks to maintain accuracy.
D. "The client does not appear to have any injuries resulting from the fall." This statement is subjective and may be misleading. A client could have internal injuries that are not immediately visible. Instead, the nurse should document a detailed physical assessment, such as "No visible injuries noted. Client denies pain or discomfort at this time."
Correct Answer is A
Explanation
A. Measure the duration of the seizure. Monitoring the duration of a seizure is critical in determining whether it is self-limiting or prolonged. Seizures lasting longer than five minutes may indicate status epilepticus, requiring emergency intervention. Documenting the start and end times helps guide appropriate medical management.
B. Restrain the client's arms and legs to prevent injury. Restraining a client during a seizure can cause musculoskeletal injury or increase agitation. Instead, the nurse should ensure the client is in a safe position, remove nearby hazards, and allow the seizure to run its course while protecting the head.
C. Insert an oral airway into the client's mouth. Forcing an airway device or object into a seizing client's mouth can cause oral trauma, aspiration, or obstruction. The priority is to maintain a patent airway by positioning the client on their side to allow secretions to drain and prevent aspiration.
D. Lower the side rails of the bed when the seizure begins. Lowering the side rails increases the risk of the client falling out of bed during convulsions. If the client is already in bed, keeping the side rails up and padded can help prevent injury while allowing safe observation of the seizure activity.
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