A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant.
The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?
Chadwick’s sign.
Chvostek’s sign.
Goodell’s sign.
Cullen’s sign.
The Correct Answer is D
Choice A rationale
Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. This sign is commonly seen in early pregnancy, but it does not indicate the presence of blood in the peritoneum.
Choice B rationale
Chvostek’s sign is a clinical sign of existing nerve hyperexcitability seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. This sign is not related to a ruptured ectopic pregnancy.
Choice C rationale
Goodell’s sign is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascular softening is seen in early pregnancy. It does not indicate the presence of blood in the peritoneum.
Choice D rationale
Cullen’s sign is the appearance of bruising in the skin around the umbilicus. It occurs when there is blood in the peritoneum, or intra-abdominal bleeding. In the case of a suspected ruptured ectopic pregnancy, Cullen’s sign would indicate the presence of blood in the peritoneum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying cold compresses 20 minutes before each feeding may not be the most effective way to manage breast engorgement. Cold compresses can help to reduce swelling and relieve pain, but they do not address the underlying cause of engorgement, which is the accumulation of milk in the breasts.
Choice B rationale
Drinking herbal tea to reduce engorgement is not a proven method. While some herbs are believed to have galactagogue properties (increase milk production), they do not directly address breast engorgement. Furthermore, the safety and efficacy of many herbal remedies are not well-studied, and some may have side effects.
Choice C rationale
Letting the baby drain one breast at each feeding can help to alleviate engorgement, but it may not be sufficient if the feedings are spaced too far apart. The breasts continue to produce milk between feedings, and if the milk is not removed, engorgement can occur.
Choice D rationale
Feeding the baby every 2 hours can help to manage breast engorgement. Regular feedings help to ensure that the milk is being removed from the breasts, preventing the buildup that leads to engorgement.
Correct Answer is A
Explanation
Choice A rationale
Elevating the leg can help reduce swelling and improve blood flow, which can alleviate pain and redness in the calf. This is a non-pharmacological intervention that the client can easily do at home.
Choice B rationale
Applying cold compresses is typically used for acute injuries to reduce inflammation and numb the area. However, in the case of a postpartum client reporting pain and redness in her calf, this could potentially be a sign of a deep vein thrombosis (DVT), and applying cold compresses may not be the most appropriate intervention.
Choice C rationale
Flexing the knee while resting is not typically recommended for a client with symptoms that may indicate a DVT. This position does not promote venous return and could potentially exacerbate the condition.
Choice D rationale
Massaging the area is not recommended if a DVT is suspected, as it could dislodge a blood clot and cause a pulmonary embolism.
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