A nurse is caring for a 36-year-old female client in the emergency unit.
Complete the following sentence by using the lists of options. Upon reviewing the client's medical record, the nurse determines that the client is at risk for developing which of the following complications? Select. The nurse should recognize that the client is most likely experiencing a Select. and is at risk for developing if not treated quickly.
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Based on the given case, here's why the answer is "Threatened miscarriage" and "Hemorrhagic shock":
Threatened Miscarriage
- Positive pregnancy test: The client has a confirmed intrauterine pregnancy.
- Vaginal bleeding and cramping: The client presents with symptoms commonly associated with threatened miscarriage, such as significant abdominal cramping and moderate bleeding with clots.
- Cervical os closed: In a threatened miscarriage, the cervix remains closed, which is consistent with the physical examination findings.
Hemorrhagic Shock
- Moderate bleeding with clots: The client reports moderate bleeding which, if it continues unchecked, can lead to significant blood loss.
- Severe abdominal cramping: Severe and constant abdominal pain can be associated with heavy bleeding.
- Vital signs: Although the current vital signs are stable, prolonged or heavy bleeding can quickly lead to a drop in blood pressure and other signs of shock.
By recognizing these symptoms and acting promptly, the nurse can help prevent complications such as hemorrhagic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Phototherapy is a treatment for jaundice but is not a preventive measure. It is used after jaundice has been identified to reduce bilirubin levels in the newborn.
Choice B rationale
Suctioning excess mucus with a bulb syringe helps clear the newborn’s airways but does not have a direct role in preventing jaundice. Jaundice is related to bilirubin metabolism, not mucus accumulation.
Choice C rationale
Preparing for an exchange blood transfusion is an intervention for severe hyperbilirubinemia but is not a preventive measure for jaundice. It is used when bilirubin levels are extremely high.
Choice D rationale
Initiating early feeding helps to promote bowel movements, which assists in the excretion of bilirubin from the body. This is an effective preventive measure for jaundice, as it helps reduce the chances of bilirubin buildup.
Correct Answer is ["A","B","C"]
Explanation
Choice A: Give betamethasone 12 mg IM now and repeat in 24 hr.
- Rationale: Betamethasone is administered to accelerate fetal lung maturity in cases of preterm labor. Given the client's gestational age of 31 weeks, this intervention is appropriate to help reduce the risk of respiratory distress syndrome in the newborn.
Choice B: Begin loading dose of magnesium sulfate 9 g over 30 min.
- Rationale: Magnesium sulfate is used for neuroprotection of the fetus in preterm labor to reduce the risk of cerebral palsy. The loading dose is typically given to achieve therapeutic levels quickly.
Choice C: Position the client in a lateral position.
- Rationale: Positioning the client in a lateral position helps improve uteroplacental blood flow and can reduce the intensity of contractions, which is beneficial in managing preterm labor.
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