A client at 35 weeks gestation complains of pain whenever the baby moves.
The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.
What condition do these findings suggest?

Abruptio placenta.

Chorioamnionitis.

Round ligament strain.

Viral infection.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Abruptio placenta is a condition where the placenta prematurely separates from the uterus. It typically presents with symptoms such as vaginal bleeding, back pain, and frequent contractions. However, the symptoms described by the client do not align with this condition.

Choice B rationale

Chorioamnionitis is an infection of the membranes surrounding the fetus and is associated with prolonged labor. Symptoms include fever, abdominal pain, and fetal tachycardia. The client’s symptoms of pain when the baby moves, a high temperature, and severe abdominal or uterine tenderness on palpation align with this condition.

Choice C rationale

Round ligament strain is a common cause of pain during pregnancy, particularly in the second trimester. It is caused by the stretching of the round ligaments that support the uterus.

However, it does not cause fever or severe abdominal tenderness.

Choice D rationale

While a viral infection could potentially cause a fever, it would not typically cause severe abdominal or uterine tenderness specifically when the baby moves.

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Correct Answer is D

Explanation

Choice A rationale

While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.

Choice B rationale

Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.

Choice C rationale

Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.

Choice D rationale

Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.

A. Monitor the client’s vital signs. B. Notify the healthcare provider. C. Inspect the perineal pad. D. Encourage the client to void.

Correct Answer is D

Explanation

Choice A rationale

While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice B rationale

Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.

Choice C rationale

Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice D rationale

Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.

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A client at 35 weeks gestation complains of pain whenever the baby moves.The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.What condition do these findings suggest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is caring for a client who delivered 6 hours ago.The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

Correct Answer is D

Explanation

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A client at 35 weeks gestation complains of pain whenever the baby moves.
The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.
What condition do these findings suggest?