A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
Decreased platelet count
Increased erythrocyte sedimentation rate (ESR)
Decreased megakaryocytes
Increased WBC
The Correct Answer is A
The correct answer is A. Decreased platelet count.
A. Decreased platelet count: ITP is characterized by a decreased platelet count. It is an autoimmune disorder where the immune system attacks and destroys platelets, leading to a reduction in the number of circulating platelets.
B. Increased erythrocyte sedimentation rate (ESR): ITP is not typically associated with an increased ESR. ESR is a marker of inflammation, and ITP is primarily a disorder of platelet destruction rather than inflammation.
C. Decreased megakaryocytes: ITP is often associated with normal or increased numbers of megakaryocytes in the bone marrow. Megakaryocytes are the precursor cells for platelets, and their increased presence indicates that the bone marrow is trying to produce more platelets to compensate for the destruction occurring in the bloodstream.
D. Increased WBC: ITP primarily affects platelet counts and does not necessarily lead to an increased white blood cell (WBC) count. The primary concern in ITP is the risk of bleeding due to low platelet levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Active is incorrect. The active phase of labor typically begins when the cervix is around 4 to 6 centimeters dilated. Given that the client's cervix is already dilated to 9 cm, she has progressed beyond the active phase.
Choice B Reason:
Transition is correct. The transition phase is the final part of the first stage of labor and occurs when the cervix is dilated from 8 to 10 centimeters. In this phase, contractions are typically strong, occurring every 2 to 3 minutes, and lasting 80 to 90 seconds. The sensation of increasing rectal pressure is common during the transition phase as the baby's head descends further into the birth canal. The advanced cervical dilation to 9 cm also indicates that the client is in the transition phase, preparing for the second stage of labor.
Choice C Reason:
Latent is incorrect. The latent phase is the early part of the first stage of labor, characterized by cervical dilation from 0 to 3 or 4 centimeters. The client's cervix is already dilated to 9 cm, indicating that she has progressed well beyond the latent phase.
Choice D Reason:
Descent is incorrect. The descent phase is generally associated with the second stage of labor, during which the baby moves through the birth canal. The information provided primarily relates to the first stage of labor, specifically the transition phase, as indicated by the cervical dilation of 9 cm.
Correct Answer is B
Explanation
The correct answer is B. Uteroplacental insufficiency.
A. Umbilical cord compression is more commonly associated with variable decelerations, not late decelerations. Variable decelerations are characterized by abrupt decreases and increases in the fetal heart rate.
B. Late decelerations are indicative of uteroplacental insufficiency.
Uteroplacental insufficiency refers to a decrease in blood flow and oxygen supply from the mother to the fetus. Late decelerations occur after the peak of the contraction and may suggest inadequate oxygenation to the fetus.
C. Fetal head compression is associated with early decelerations, not late decelerations. Early decelerations typically coincide with the contractions and are considered a normal response to head compression during contractions.
D. Maternal bradycardia is not typically associated with late decelerations. Late decelerations are primarily related to issues with oxygenation and blood flow to the fetus.
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