A client is admitted with a threatened abortion. Which assessment findings would the nurse expect? Select all that apply. (Select All that Apply.)

Passage of fetal tissue

Bright red vaginal bleeding

Severe cramping and pelvic pain

Closed cervix upon examination

Mild to moderate lower abdominal cramping

Answer and Explanation

Correct Answer : B,D,E

A. Passage of fetal tissue – This finding is more consistent with an incomplete or complete abortion, not a threatened abortion.

B. Bright red vaginal bleeding – A threatened abortion involves vaginal bleeding during the first 20 weeks of pregnancy, often bright red in color. The cervix remains closed, and fetal cardiac activity may still be present.

C. Severe cramping and pelvic pain – Severe pain is more typical of an inevitable or incomplete abortion rather than a threatened abortion.

D. Closed cervix upon examination – In a threatened abortion, the cervix remains closed. If the cervix opens, the risk of progressing to an inevitable abortion increases.

E. Mild to moderate lower abdominal cramping – Mild cramping or lower abdominal discomfort is common in a threatened abortion due to uterine contractions. However, severe cramping and passage of fetal tissue would indicate a more advanced pregnancy loss.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

Preeclampsia:

Blood pressure of 150/96 mmHg: A BP of ≥140/90 mmHg on two occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive client is diagnostic of preeclampsia.

Preeclampsia with Severe Features:

Blood pressure of 162/112 mmHg: Severe hypertension is ≥160/110 mmHg on two occasions at least 4 hours apart. This is a criterion for severe preeclampsia, requiring immediate intervention to prevent complications like eclampsia or stroke.

Elevated liver enzymes (ALT/AST > 2x the upper limit of normal) are indicative of severe preeclampsia due to hepatic involvement. This can progress to HELLP syndrome, increasing the risk of liver rupture and disseminated intravascular coagulation (DIC).

Neither:

Negative for protein on a urine dipstick: Preeclampsia is typically diagnosed with proteinuria (≥300 mg in 24 hours or protein/creatinine ratio ≥0.3). A negative urine dipstick means proteinuria is absent, making preeclampsia unlikely. However, preeclampsia can also be diagnosed without proteinuria if other systemic features (e.g., thrombocytopenia, renal dysfunction) are present.

Seizures in a client with preeclampsia indicate eclampsia, which is a medical emergency requiring magnesium sulfate to prevent further seizures. If the client had no preeclampsia, the seizures could be due to another cause (e.g., epilepsy, metabolic disturbance).

A. Slurred speech B. Respiratory depression C. Decreased sensation in the lower extremities D. Sustained fetal heart rate of 150 bpm E. Blood pressure 108/62

Correct Answer is ["A","B"]

Explanation

A. Slurred speech – Slurred speech may indicate systemic absorption of the epidural medication, leading to toxicity or excessive central nervous system depression, which requires immediate intervention.

B. Respiratory depression – A serious complication of epidural anesthesia is respiratory depression, which may result from excessive medication spread, affecting respiratory function. Immediate intervention is required.

C. Decreased sensation in the lower extremities – This is an expected effect of an epidural and does not necessarily require immediate reporting unless it extends beyond expected levels.

D. Sustained fetal heart rate of 150 bpm – This fetal heart rate is within the normal range (110-160 bpm) and does not indicate distress.

E. Blood pressure 108/62 – While hypotension can be a side effect of epidural anesthesia, this blood pressure is within an acceptable range for many clients and does not require immediate intervention unless the client is symptomatic.

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A client is admitted with a threatened abortion. Which assessment findings would the nurse expect? Select all that apply. (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST) As the nurse, you can identify whether the following findings are indicative of preeclampsia, preeclampsia with severe features, or neither. Select at least one answer in each row.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

The nurse is monitoring a client in active labor who has an epidural in place. Which of the following findings should be reported to the anesthesiologist immediately? (Select All that Apply.)

Correct Answer is ["A","B"]

Explanation

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A client is admitted with a threatened abortion. Which assessment findings would the nurse expect? Select all that apply. (Select All that Apply.)

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