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 A
Explanation
A. This is the correct answer. A snug-fitting bra helps suppress lactation and provides support to relieve discomfort. It should be worn continuously, even while sleeping, for 72 hours.
B. Moist heat stimulates milk production and should be avoided. Instead, cold compresses can help reduce swelling.
C. Fluid restriction is not necessary and could lead to dehydration.
D. Manually expressing milk will encourage continued milk production rather than suppressing lactation.
Correct Answer is C
Explanation
A. Wire cutters – These are used in clients with wired jaws, not for chest tube management.
B. Tracheostomy tray – This is necessary for airway emergencies but is not specific to chest tube management.
C. Padded clamp – This is the correct answer because a padded clamp is used to assess for air leaks, check chest tube patency, or temporarily clamp the tube if needed during troubleshooting or before removal.
D. Sand bag – A sandbag is not necessary for a client with a chest tube; it is more commonly used for stabilizing orthopedic injuries.
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