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 C
Explanation
Choice A rationale
A reaction from an epidural can cause side effects such as hypotension and shivering, but it is not related to tachysystole.
Choice B rationale
When the fetus's heart rate drops below baseline, it is termed bradycardia, not tachysystole. This condition can occur due to various reasons, including cord prolapse or placental insufficiency.
Choice C rationale
Tachysystole is defined as more than five contractions in 10 minutes. This condition can lead to reduced blood flow to the fetus, resulting in fetal distress.
Choice D rationale
Pitocin is a medication used to induce labor and can cause tachysystole, but the administration of Pitocin itself is not the definition of tachysystole. It's the increased frequency of contractions that defines the condition.
Correct Answer is C
Explanation
Choice A rationale
Assessing the client's blood pressure can help determine if there is a significant loss of blood and consequent hypotension. However, it is not the immediate first action to manage heavy bleeding postpartum.
Choice B rationale
Assessing the bladder for distention is crucial as a full bladder can interfere with uterine contraction, potentially leading to increased bleeding. But, it isn't the first priority compared to addressing the immediate bleeding.
Choice C rationale
Massaging the client's fundus is the priority action in this case. It helps to contract the uterus, thereby reducing bleeding. Uterine atony is the most common cause of postpartum hemorrhage, and fundal massage is the first intervention to manage it.
Choice D rationale
Preparing to administer a prescription may be necessary, especially if uterotonics are required. However, this is a subsequent step after attempting to control the bleeding through fundal massage.
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