A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contractions. The client's blood pressure is 88/50 mm Hg and her abdomen is rigid. The nurse should identify these findings as Indicating which of the following complications?
Placental abruption
Amniotic fluid embolus
Placenta previa
Uterine rupture
The Correct Answer is A
A. Placental abruption – This is the correct answer because placental abruption occurs when the placenta detaches prematurely from the uterine wall, leading to severe abdominal pain, vaginal bleeding, uterine rigidity, and signs of hypovolemic shock (low blood pressure). The hallmark sign is a painful, rigid abdomen with contractions.
B. Amniotic fluid embolus – This condition presents with sudden respiratory distress, hypotension, and disseminated intravascular coagulation (DIC), but it does not typically cause uterine rigidity or persistent contractions.
C. Placenta previa – Placenta previa typically presents with painless vaginal bleeding rather than severe abdominal pain and a rigid uterus.
D. Uterine rupture – Uterine rupture is usually associated with a history of uterine surgery (e.g., previous cesarean section). It presents with sudden, severe pain followed by cessation of contractions, not persistent contractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Data comparison should be done after establishing the standards and collecting data.
B. While data collection is important, the first step is to determine what the accepted hand hygiene standards are.
C. This is the correct answer. The first step in an audit process is to determine the accepted hand hygiene standards to provide a basis for evaluation.
D. Corrective measures should only be taken after data has been collected and analyzed.
Correct Answer is A
Explanation
A. This is the correct answer. Older adults are at risk for fluid overload, so infusing blood over 4-5 hours (instead of the usual 2-4 hours) is safer.
B. Blood products must be infused with 0.9% sodium chloride (normal saline) only. Dextrose-containing solutions cause hemolysis.
C. A 20-gauge catheter is acceptable, but a larger bore (18-gauge) is preferred for faster infusion.
D. Vital signs should be monitored before the transfusion, 15 minutes after starting, then every 30-60 minutes, and at completion.
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