A nurse is assisting with the care of a female client who is at 28 weeks of gestation in the maternity unit.
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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Mongolian spots are common, benign skin markings that some newborns have, but they are not related to rubella exposure during pregnancy.
Choice B rationale
Jaundice is a common condition in newborns, characterized by a yellowing of the skin and eyes, usually due to an immature liver. It's not specifically linked to maternal rubella exposure.
Choice C rationale
Transient strabismus, or temporary misalignment of the eyes, can occur in newborns but is unrelated to rubella. It usually resolves on its own as the newborn's muscles develop.
Choice D rationale
Deafness is a significant risk associated with congenital rubella syndrome. Rubella can damage the developing auditory system in utero, leading to permanent hearing loss in the newborn.
Correct Answer is B
Explanation
Choice A rationale
"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.
Choice B rationale
"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.
Choice C rationale
"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.
Choice D rationale
"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.
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