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 B
Explanation
Choice A rationale
Immediately after delivery, the breasts of a new mother are not likely to remain the same as before delivery. Hormonal changes during pregnancy prepare the breasts for lactation, and these changes do not typically revert immediately after delivery.
Choice B rationale
On the first postpartum day, the breasts of a new mother are most likely to be filling and secreting colostrum. Colostrum is the first form of milk produced by the mammary glands, and it usually starts to be produced during pregnancy and continues during the early days of breastfeeding.
Choice C rationale
An immediate let-down response is not typically observed on the first postpartum day. The letdown reflex, which releases milk from the breast, usually becomes more pronounced after the first few days of breastfeeding.
Choice D rationale
While the breasts may become larger due to milk production, they are not typically very tender to touch on the first postpartum day. Tenderness may occur later, especially if complications like engorgement or mastitis develop.
Correct Answer is C
Explanation
Choice A rationale
Administering oxygen via a facemask is an intervention that can be used if the baby shows signs of distress or if the decelerations do not improve with other interventions. However, it is not the first action that should be taken.
Choice B rationale
Turning off the oxytocin infusion could be an appropriate action if the mother is receiving oxytocin and the baby is showing signs of distress. However, it is not the first action that should be taken.
Choice C rationale
Changing the client’s position is the correct first action for variable decelerations. This can relieve potential cord compression and improve fetal oxygenation.
Choice D rationale
Assessing cervical dilation is an important part of monitoring labor progress, but it is not the first action that should be taken in response to variable decelerations.
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