The student nurse is assessing a woman with abruptio placentae. The student reports to the registered nurse, "I can't really palpate her abdomen, it's as hard as a board." What action by the nurse is the priority?
Assess the woman's fundal height and vital signs.
Administer a dose of opioid pain medication.
Tell the student to document the findings.
Have the student teach the woman relaxation techniques.
The Correct Answer is A
Choice A: This is the correct answer because a hard and tender abdomen is a sign of concealed hemorrhage, which can lead to hypovolemic shock and fetal distress. The nurse needs to monitor the woman's blood loss, blood pressure, pulse, and fetal heart rate to detect any complications and intervene accordingly.
Choice B: This is incorrect because opioid pain medication can mask the signs of shock and fetal distress, and may also cause respiratory depression in both the mother and the fetus. Pain relief should be given after assessing the woman's condition and consulting with the physician.
Choice C: This is incorrect because documenting the findings is not a priority action. The nurse needs to act quickly to prevent further blood loss and fetal compromise, and report the findings to the physician.
Choice D: This is incorrect because relaxation techniques may not be effective in reducing the pain and anxiety caused by abruptio placentae. The nurse should provide emotional support and reassurance to the woman, but also focus on assessing and managing her physical condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a) A phase of the female menstrual cycle that involves the release of an egg (ovum) from one of the ovaries is incorrect because this is not the definition of Mittelschmerz, but rather the definition of ovulation. Ovulation is the process by which one or more eggs are released from the ovaries and travel to the fallopian tubes, where they can be fertilized by sperm. Ovulation usually occurs around the middle of the menstrual cycle, which is typically 28 days long, but can vary from person to person. Ovulation can be detected by changes in basal body temperature, cervical mucus, or hormone levels. Therefore, this response is inaccurate and misleading.
Choice B) A female reproductive organ in which ova or eggs are produced is incorrect because this is not the definition of Mittelschmerz, but rather the definition of ovary. The ovary is a paired organ that is located on either side of the uterus in the lower abdomen. The ovary contains thousands of follicles, which are sacs that contain immature eggs. Each month, one or more follicles mature and release an egg during ovulation. The ovary also produces hormones such as estrogen and progesterone, which regulate the menstrual cycle and pregnancy. Therefore, this response is irrelevant and inaccurate.
Choice C) The regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina is incorrect because this is not the definition of Mittelschmerz, but rather the definition of menstruation. Menstruation is the process by which the endometrium, which is the tissue that lines the uterus and prepares for implantation of a fertilized egg, is shed and expelled through the vagina if pregnancy does not occur. Menstruation usually occurs once a month and lasts for about 3 to 7 days, but can vary from person to person. Menstruation can be accompanied by symptoms such as cramps, bloating, mood swings, or headaches. Therefore, this response is irrelevant and inaccurate.
Choice D) One-sided, lower belly pain associated with normal ovulation. Usually occurs about 14 days before the next menstrual period is correct because this is the definition of Mittelschmerz. Mittelschmerz is a German word that means "middle pain". It refers to a mild to moderate pain or discomfort that some women experience in their lower abdomen around the time of ovulation. The pain may last for a few minutes to a few hours and may switch sides from month to month depending on which ovary releases an egg. The pain may be caused by irritation or stretching of the ovarian or abdominal wall by the maturing follicle or by fluid or blood released during ovulation.
Mittelschmerz is not a sign of any disease or problem and does not require any treatment. However, it can be confused with other conditions that cause pelvic pain, such as appendicitis, ectopic pregnancy, or ovarian cysts. Therefore, women who have severe or persistent pain should consult their doctor for diagnosis and treatment. Therefore, this response is clear and accurate.
Correct Answer is D
Explanation
Choice A: This is incorrect because both physiological and nonphysiological jaundice result from breakdown of erythrocytes. Jaundice is caused by the accumulation of bilirubin, a yellow pigment that is produced when red blood cells are destroyed. However, the rate and extent of hemolysis differ between the two types of jaundice.
Choice B: This is incorrect because kernicterus is a rare and serious complication of jaundice, not a usual outcome. Kernicterus occurs when bilirubin levels are very high and the pigment deposits in the brain, causing neurological damage. It can affect both physiological and nonphysiological jaundice, but it is more likely to occur in nonphysiological jaundice due to higher bilirubin levels and underlying conditions.
Choice C: This is incorrect because both physiological and nonphysiological jaundice begin at the head and progress down the body. This is because bilirubin accumulates in areas with high fat content, such as the skin, eyes, and brain. The distribution of jaundice depends on the level of bilirubin in the blood, not on the type of jaundice.
Choice D: This is the correct answer because nonphysiological jaundice appears in the first 24 hours of life, whereas physiological jaundice appears after the first 24 hours of life. Nonphysiological jaundice is caused by factors that increase hemolysis or impair bilirubin metabolism or excretion, such as blood group incompatibility, infection, liver disease, or enzyme deficiency. Physiological jaundice is caused by normal adaptation processes that occur after birth, such as increased red blood cell turnover, immature liver function, and delayed intestinal flora colonization.
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