A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?
Hemorrhage
Edema
Infection
Jaundice
The Correct Answer is A
Choice A reason: Hemorrhage is the most life-threatening complication of a ruptured ectopic pregnancy, as it can lead to hypovolemic shock and death. The nurse should monitor the client's vital signs, blood loss, and level of consciousness, and administer fluids and blood products as ordered.
Choice B reason: Edema is not a common sign of a ruptured ectopic pregnancy, and it is not a priority over hemorrhage. Edema may be caused by other conditions, such as heart failure, kidney disease, or venous insufficiency.
Choice C reason: Infection is a possible complication of a ruptured ectopic pregnancy, but it is not as urgent as hemorrhage. Infection may manifest as fever, chills, malaise, or foul-smelling vaginal discharge. The nurse should administer antibiotics as ordered and monitor the client's temperature and white blood cell count.
Choice D reason: Jaundice is not a typical symptom of a ruptured ectopic pregnancy, and it is not a priority over hemorrhage. Jaundice may indicate liver dysfunction or hemolytic anemia, which are unrelated to ectopic pregnancy. The nurse should assess the client's skin and sclera color, and check the liver enzymes and bilirubin levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Vitamin E requirements do not decrease during pregnancy due to the increase in body fat. Vitamin E is a fat-soluble vitamin that acts as an antioxidant and protects cell membranes from oxidative damage. The recommended dietary allowance (RDA) for vitamin E during pregnancy is 15 mg/day, which is the same as for non-pregnant women.
Choice B: Prenatal vitamins will meet your need for increased folic acid during pregnancy. Folic acid is a water-soluble vitamin that is essential for DNA synthesis and cell division. Folic acid deficiency can cause neural tube defects in the fetus, such as spina bifida and anencephaly. The RDA for folic acid during pregnancy is 600 mcg/day, which can be obtained from prenatal vitamins and fortified foods.
Choice C: You will not need to double your intake of protein during pregnancy. Protein is a macronutrient that provides amino acids for tissue growth and repair. The RDA for protein during pregnancy is 1.1 g/kg/day, which is only slightly higher than for non-pregnant women (0.8 g/kg/day).
Choice D: You will not need to increase your intake of calcium during pregnancy. Calcium is a mineral that is important for bone health and muscle contraction. Calcium absorption and retention are enhanced during pregnancy, so there is no need to increase the intake above the RDA of 1000 mg/day for women aged 19 to 50 years.
Correct Answer is ["C","D","E"]
Explanation
Choice A: Absence of pain is not a sign of abruptio placenta. Abruptio placenta is a condition where the placenta separates from the uterine wall before delivery, causing bleeding and pain. The pain is usually severe and constant.
Choice B: Insidious onset is not a sign of abruptio placenta. Abruptio placenta is usually a sudden and acute event that occurs in the third trimester or during labor.
Choice C: Dark red vaginal bleeding is a sign of abruptio placenta. The bleeding is caused by the rupture of blood vessels between the placenta and the uterus. The blood may be dark red because it is old or clotted.
Choice D: Rigid uterus is a sign of abruptio placenta. The uterus becomes hard and tense as a result of the bleeding and contraction of the uterine muscles. This can impair the blood flow to the fetus and cause fetal distress.
Choice E: Absent fetal heart tones is a sign of abruptio placenta. The loss of blood and oxygen to the fetus can cause fetal death or stillbirth. Fetal heart tones can be detected by using a Doppler device or a fetoscope.
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