A female client is admitted to the emergency department complaining of severe left lower quadrant pain and vaginal bleeding.
What would be the priority assessment by the nurse at this time?
Assess the client for a fever.
Ask the client when she last voided.
Ask the client about the date of her last menstrual period.
Ask the client about her last bowel movement.
The Correct Answer is C
Choice A rationale
Fever assessment is a common nursing intervention used to identify inflammatory or infectious processes like pelvic inflammatory disease or appendicitis. Normal body temperature ranges from 97.0 F to 99.0 F. While a fever would provide diagnostic clues, it is not the most immediate priority when a client presents with severe localized pain and vaginal bleeding, which may indicate a life-threatening ruptured ectopic pregnancy requiring rapid surgical or medical intervention.
Choice B rationale
Identifying the timing of the last void helps the nurse assess bladder function and potential urinary tract involvement in abdominal pain. However, urinary status is secondary to the need for a focused reproductive history in this clinical scenario. While a full bladder could exacerbate discomfort or interfere with a physical examination, it does not provide the critical information needed to determine if the client is experiencing a gynecological emergency that compromises systemic stability.
Choice C rationale
Determining the date of the last menstrual period is the highest priority because it helps the nurse assess the possibility of pregnancy. Severe lower quadrant pain and vaginal bleeding in a woman of childbearing age are classic signs of an ectopic pregnancy. Rapid identification of pregnancy status allows the healthcare team to prioritize life-saving interventions, as rupture can lead to massive internal hemorrhage, hypovolemic shock, and rapid maternal physiological decline.
Choice D rationale
Asking about the last bowel movement helps evaluate gastrointestinal causes of abdominal pain, such as constipation or bowel obstruction. While gastrointestinal issues can cause lower quadrant distress, they are generally less acute than a suspected ruptured ectopic pregnancy. In an emergency setting, the nurse must first rule out the most lethal possibilities related to the client's specific symptoms of vaginal bleeding combined with severe localized pelvic pain before exploring digestive issues.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While it is true that screening identifies non-immune clients, the rubella vaccine is a live attenuated virus and is strictly contraindicated during pregnancy due to the theoretical risk of congenital rubella syndrome. Immunization can only be administered in the immediate postpartum period, and the client must be advised to avoid pregnancy for at least 28 days following the injection. Therefore, screening does not determine candidacy for immunization during the current pregnancy but for future protection.
Choice B rationale
The rubella screening, or rubella titer, measures the level of IgG antibodies in the maternal serum. It is used to determine current immunity levels rather than assessing the risk of teratogenic effects from a vaccination that occurred in the past. Previous vaccination is intended to provide long-term protection, and the test simply verifies if those antibodies are still present at a functional level of 1: or greater to protect the developing fetus from future exposure.
Choice C rationale
Rubella is not characterized by a carrier state in the way that some other viral or bacterial infections are. A person is either susceptible, acutely infected, or immune. The screening is designed to detect the presence of protective antibodies, not to identify the client as a chronic carrier of the virus. Understanding this distinction is important for accurate clinical interpretation of the lab results and for providing the client with correct information about their health status.
Choice D rationale
The rubella titer is performed to confirm that the client has a sufficient level of antibodies to prevent an active infection if exposed to the virus during pregnancy. Maternal rubella infection, especially during the first trimester, carries a high risk of causing congenital rubella syndrome, which can lead to deafness, cataracts, and cardiac defects in the newborn. A titer of 1: or higher indicates immunity, while a lower titer suggests the client is non-immune and vulnerable.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Cocaine is a potent vasoconstrictor that causes a rapid increase in maternal blood pressure and significant uterine artery constriction. This sudden vascular compromise can lead to premature separation of the placenta from the uterine wall, known as placenta abruption. This condition is a life-threatening emergency for both the mother and the fetus due to the risk of severe hemorrhage and impaired fetal oxygenation caused by the drug's sympathetic nervous system stimulation.
Choice B rationale
Erythroblastosis fetalis is a hemolytic disease of the newborn that occurs due to Rh incompatibility between the mother and the fetus. It involves the maternal immune system producing antibodies that attack fetal red blood cells. There is no known scientific or physiological link between the use of cocaine and the development of Rh isoimmunization or hemolytic anemia. This condition is strictly related to blood group antigens rather than substance abuse or maternal vasoconstriction.
Choice C rationale
The systemic effects of cocaine involve the inhibition of norepinephrine reuptake at nerve endings, leading to a state of chronic sympathetic overactivity. This results in persistent vasoconstriction and increased peripheral vascular resistance, which manifests as gestational hypertension. The cardiovascular strain placed on the mother by regular cocaine use increases the likelihood of developing preeclampsia or other hypertensive disorders of pregnancy, which can have devastating effects on maternal organ systems and placental perfusion.
Choice D rationale
Cocaine use during pregnancy causes chronic intrauterine hypoxia due to decreased blood flow through the placental bed. When the fetus is deprived of adequate oxygen and essential nutrients over a long period, growth is significantly restricted. This often results in the infant being small for gestational age at birth. The vasoconstrictive properties of the drug limit the transfer of glucose and amino acids, which are necessary for normal fetal weight gain and development.
Choice E rationale
Substance abuse is frequently associated with various lifestyle factors, including poor nutritional intake. Cocaine acts as a powerful appetite suppressant, which often leads to the mother neglecting her caloric and vitamin requirements. Inadequate maternal nutrition further compounds the risks to the fetus, as the lack of essential building blocks like folic acid, iron, and protein can lead to anemia, low birth weight, and other developmental complications during the gestation period.
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