A nurse is assisting with the care of a female client who is at 28 weeks of gestation in the maternity unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

An ectopic pregnancy is most likely due to the combination of symptoms: dizziness, pale skin, cool extremities, low blood pressure (86/48 mm Hg), and high heart rate (120/min). The soft and non-tender abdomen with no palpable contractions also suggests an ectopic pregnancy rather than other conditions. The low hematocrit (25%) and hemoglobin (9 g/dL) indicate significant blood loss, a hallmark of ectopic pregnancy.

Administer methotrexate is important to stop the growth of the embryo in an ectopic pregnancy. Insert a large-bore peripheral IV catheter to manage blood loss and prepare for potential surgery.

Monitoring beta human chorionic gonadotropin (hCG) levels is crucial to confirm the diagnosis and monitor treatment response. Platelet count should be monitored due to the risk of bleeding associated with an ectopic pregnancy.

Placenta previa usually presents with painless vaginal bleeding, which is absent in this case. Chorioamnionitis is typically associated with infection signs like fever, uterine tenderness, and elevated white blood cell count, not primarily dizziness and low blood pressure. Cervical insufficiency usually presents with painless cervical dilation, leading to preterm birth, not the acute signs seen here. Vaginal bleeding is a symptom, not a diagnosis, and this client reports no vaginal bleeding.

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Correct Answer is D

Explanation

Choice A rationale

Lecithin/sphingomyelin (L/S) ratio does not indicate genetic disorders; it's used to assess fetal lung maturity.

Choice B rationale

The test does not determine placental function. It specifically evaluates fetal lung maturity through the ratio of lecithin to sphingomyelin in amniotic fluid.

Choice C rationale

The test is not used to assess the risk of Rh incompatibility. The L/S ratio focuses on lung development rather than blood compatibility issues.

Choice D rationale

The L/S ratio assesses the baby's lung maturity, indicating if the lungs produce enough surfactant for proper function after birth.

A. Assist the client's partner to apply counterpressure to the sacrum. B. Maintain the client on bed rest until active labor begins. C. Insert an indwelling urinary catheter. D. Teach the client to hold their breath during contractions.

Correct Answer is A

Explanation

Choice A rationale

Assisting the client's partner to apply counterpressure to the sacrum can help alleviate the low-back pain associated with early labor by providing direct pressure to the area experiencing discomfort.

Choice B rationale

Maintaining the client on bed rest until active labor begins is not typically recommended, as mobility can help with the progression of labor and pain management.

Choice C rationale

Inserting an indwelling urinary catheter is not necessary for managing low-back pain in early labor and can increase the risk of infection and discomfort.

Choice D rationale

Teaching the client to hold their breath during contractions is not advisable, as it can lead to increased pain and decreased oxygenation for both the mother and baby. Breathing techniques are usually recommended to manage pain and ensure adequate oxygen delivery. .

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is undergoing amniotic fluid assessment for the lecithin/sphingomyelin ratio.Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who is in early labor and reports low-back pain during contractions.Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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