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 their abdomen is rigid. The nurse should identify these findings as indicating which of the following complications?

Placental abruption

Uterine rupture

Placenta previa

Amniotic fluid embolus

Answer and Explanation

The Correct Answer is A

A. Placental abruption: Placental abruption is characterized by the premature separation of the placenta from the uterine wall before delivery of the fetus. Sudden, severe abdominal pain, moderate to severe vaginal bleeding, persistent uterine contractions, and uterine rigidity are classic signs and symptoms of placental abruption. Hypotension may occur due to hemorrhage, leading to decreased perfusion to vital organs.
B. Uterine rupture: Uterine rupture involves a tear in the uterine wall, which can lead to severe abdominal pain, vaginal bleeding, and signs of shock. However, uterine rupture typically occurs during labor or delivery, particularly in women with a history of uterine surgery or trauma.
C. Placenta previa: Placenta previa is characterized by the implantation of the placenta over or near the internal cervical os. It can cause painless vaginal bleeding in the third trimester, particularly after 20 weeks of gestation. However, it is not typically associated with severe abdominal pain or uterine rigidity.
D. Amniotic fluid embolus: An amniotic fluid embolus occurs when amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, leading to a potentially life-threatening reaction. Symptoms may include sudden dyspnea, hypotension, cardiovascular collapse, and disseminated intravascular coagulation (DIC). While it can cause severe complications, the symptoms described in the scenario are more consistent with placental abruption.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Acute hemolytic:
Acute hemolytic transfusion reactions typically present with symptoms such as fever, chills, flank pain, hemoglobinuria (blood in the urine), and possibly hypotension. This occurs due to the rapid destruction of transfused red blood cells, often because of ABO incompatibility between the donor and recipient. The symptoms described in the scenario, including chest tightness, are not consistent with acute hemolytic reactions.

B. Allergic:
Allergic reactions to blood transfusions can manifest with symptoms such as itching, hives, flushing, and mild respiratory distress. While headache and low-back pain can occur in allergic reactions, the feeling of "tightness" in the chest is more indicative of another type of reaction.

C. Bacterial:
Bacterial contamination of blood products can lead to transfusion-related sepsis. Symptoms may include fever, chills, hypotension, and rapid onset of shock. However, the presence of headache and low-back pain, along with chest tightness, is not typically associated with bacterial contamination.

D. Febrile nonhemolytic:
Febrile nonhemolytic transfusion reactions are characterized by fever, chills, and rigors. While fever and chills are common symptoms, they do not typically cause chest tightness or low-back pain.

A. Initiate IV access on the palmar side of the client's wrist. B. Choose the client's dominant arm for IV access whenever possible. C. Select a site proximal to previous venipuncture sites. D. Insert a larger gauge IV catheter to prevent phlebitis.

Correct Answer is C

Explanation

A. Initiate IV access on the palmar side of the client's wrist. - This option is not recommended because veins on the palmar side of the wrist are smaller and more prone to infiltration and nerve damage. The dorsal aspect of the hand or forearm is typically preferred for peripheral IV access due to larger veins and decreased risk of complications.
B. Choose the client's dominant arm for IV access whenever possible. - While it may be convenient to select the dominant arm for IV access, it is not always the best choice. Factors such as previous venipunctures, condition of veins, and patient comfort should be considered when selecting the site for IV insertion.
C. Select a site proximal to previous venipuncture sites. - This is the correct action. Choosing a site proximal (above) to previous venipuncture sites helps preserve veins and reduces the risk of venous sclerosis or phlebitis. It allows for better vein integrity and decreases the likelihood of complications associated with repeated punctures in the same area.
D. Insert a larger gauge IV catheter to prevent phlebitis. - Inserting a larger gauge IV catheter is not necessary to prevent phlebitis. In fact, using a larger gauge catheter may increase the risk of phlebitis and other complications. The appropriate gauge of the catheter depends on the client's condition, the type of fluids or medications to be administered, and the condition of the veins.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

Correct Answer is A

Explanation

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn. Which of the following instructions should the nurse include?

A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?

A nurse is evaluating the progress of a school-age child who takes methylphenidate. Which of the following findings indicates the effectiveness of the medication?