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 A
Explanation
If the umbilical cord is protruding from the vagina, it’s a medical emergency known as cord prolapse. The nurse should insert a gloved hand into the vagina to relieve pressure on the cord. This is done to prevent cord compression, which could cut off the baby’s oxygen supply.
Correct Answer is A
Explanation
Choice A rationale
Applying lotion to the newborn’s skin during phototherapy is not recommended. Lotion can block the light from reaching the skin and reduce the effectiveness of the treatment.
Choice B rationale
Covering the newborn’s eyes with a mask during phototherapy is a standard practice. This is done to protect the newborn’s eyes from the intense light used in phototherapy.
Choice C rationale
An increase in stool frequency is expected during phototherapy. This is because phototherapy helps to break down bilirubin, which is then excreted in the stool.
Choice D rationale
A pink rash on the newborn’s trunk does not require intervention during phototherapy. It could be a common newborn rash that will resolve on its own.
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