A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks of gestation and reports continuous abdominal pain and dark red vaginal bleedinG. The tocodynamometer shows low amplitude high frequency uterine activity. The nurse should identify that the client is likely experiencing which of the following complications? (Select onE.:
Prolapsed cord
Premature rupture of membranes
Abruptio placentae
Placenta previa
The Correct Answer is C
Choice A: Prolapsed cord is not a likely complication, as it is characterized by a sudden onset of severe variable decelerations of the fetal heart rate and a visible or palpable cord in the vaginA. The nurse should identify a prolapsed cord as a medical emergency and perform immediate interventions to relieve the cord compression and deliver the fetus.
Choice B: Premature rupture of membranes is not a likely complication, as it is characterized by a gush or a trickle of clear or yellowish fluid from the vagina and a positive nitrazine or fern test. The nurse should identify premature rupture of membranes as a risk factor for infection and monitor the fetal heart rate and the maternal temperaturE.
Choice C: Abruptio placentae is a likely complication, as it is characterized by continuous abdominal pain and dark red vaginal bleeding and a board-like abdomen. The nurse should identify abruptio placentae as a life-threatening condition that involves the premature separation of the placenta from the uterine wall and can cause fetal distress and maternal hemorrhagE.
Choice D: Placenta previa is not a likely complication, as it is characterized by painless bright red vaginal bleeding and a soft and relaxed uterus. The nurse should identify placenta previa as a condition that involves the abnormal implantation of the placenta near or over the cervical os and can cause fetal hypoxia and maternal hemorrhagE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B. Report the client's temperature elevation is incorrect. The client's temperature is within the normal range for a postpartum woman, which can be slightly elevated due to dehydration, increased metabolism, or breast engorgement. A fever of 38°C (100.4°F. or higher could indicate an infection and should be reporteD.
Choice C. Increase IV fluids is incorrect. The client does not have signs of hypovolemia or dehydration that would require increased IV fluids. Excessive fluid administration can cause fluid overload and pulmonary edema in postpartum women.
Choice D. Encourage the client to nurse more frequently so her milk will come in is incorrect. The client's breasts are soft, which indicates that her milk has not come in yet. Nursing more frequently will stimulate milk production, but it will not help with the current problem of uterine atony and hemorrhagE. The nurse should massage the fundus and administer oxytocin as prescribed to enhance uterine contraction.
Correct Answer is B
Explanation
Choice A: Copious vaginal bleeding is not a typical sign of ectopic pregnancy. It may occur in some cases, but it is more likely to indicate a miscarriage, placenta previa, or placental abruption.
Choice B: Pelvic pain is the most common symptom of ectopic pregnancy. It usually occurs on one side of the lower abdomen and may be sharp, dull, or crampinG. The pain may worsen with movement or pressurE.
Choice C: Severe nausea and vomiting are not specific to ectopic pregnancy. They may occur in any pregnancy, especially in the first trimester. They may also be caused by other conditions, such as gastroenteritis, food poisoning, or appendicitis.
Choice D: Uterine enlargement greater than expected for gestational age is not a sign of ectopic pregnancy. It may indicate a multiple pregnancy, a molar pregnancy, or a large fibroiD. Ectopic pregnancy usually causes a smaller-than-normal uterus, because the embryo is not implanted in the uterine cavity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.