A client at 38-weeks gestation reports experiencing severe abdominal pain.
Upon palpation, the nurse notes that the abdomen is rigid.
How should the nurse document the findings?
Placenta previa.
Oligohydramnios.
Abruptio placenta.
Chorioamnionitis.
The Correct Answer is C
Choice A rationale
Placenta previa is a condition where the placenta covers the cervix, which can cause painless bleeding, not severe abdominal pain.
Choice B rationale
Oligohydramnios refers to a condition where there is less amniotic fluid around the baby in the womb. It does not typically cause severe abdominal pain.
Choice C rationale
Abruptio placenta is a serious condition where the placenta detaches from the uterus before the baby is born. It can cause severe abdominal pain and a rigid abdomen, which matches the symptoms described.
Choice D rationale
Chorioamnionitis is an infection of the membranes surrounding the fetus and the amniotic fluid. It typically presents with fever and increased heart rate, not necessarily severe abdominal pain and a rigid abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While using gestures with 1 to 2 word sentences is a developmental milestone, it is typically seen in younger children, around the age of 212.
Choice B rationale
Using 1 word sentences is a developmental milestone usually achieved by children around the age of 112. By the age of 3, children are typically able to speak in simple sentences with four or more words.
Choice C rationale
Speaking in simple sentences with four or more words is a typical developmental milestone for a 3-year-old child. They are able to express their thoughts more clearly and engage in conversations.
Choice D rationale
Recognizing most letters and numbers is a skill that is typically developed around the age of 4 or 512. Therefore, expecting a 3-year-old child to recognize most letters and numbers might be too advanced for their developmental stage.
Correct Answer is A
Explanation
Choice A rationale
Monitoring the capillary refill of the toes is crucial when a child has a long-leg cast applied. This is because it helps assess the adequacy of circulation to the foot, which can be compromised by the cast. If the capillary refill is delayed (more than 2 seconds), it could indicate poor blood flow to the area, which could lead to serious complications such as tissue necrosis.
Choice B rationale
Comparing the temperature of both legs can provide information about circulation and inflammation. However, it is not the most important action in this case. While a significant difference in temperature could indicate a problem, it is not as direct an indicator of circulatory status as capillary refill.
Choice C rationale
Observing for spontaneous movement can provide information about nerve function. If the child is not moving the toes, it could indicate nerve damage. However, lack of movement could also be due to discomfort from the cast and is not as direct an indicator of circulatory status as capillary refill.
Choice D rationale
Checking the femoral pulses can provide information about circulation to the leg. However, the femoral pulse is proximal to the cast and may not accurately reflect circulation to the foot. Therefore, it is not the most important action in this case.
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