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 A
Explanation
Choice A rationale
Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing fever promptly is a priority to stabilize both maternal and fetal conditions.
Choice B rationale
Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the overall clinical picture should be prioritized.
Choice C rationale
Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics and hydration.
Choice D rationale
Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential complications.
Correct Answer is A
Explanation
Choice A rationale
Acknowledging the client’s feelings provides emotional support and validates her experience. This response opens the door for further discussion and support, which is crucial for emotional well-being.
Choice B rationale
Suggesting future possibilities does not address the client's current emotional state. It may come across as dismissive of her feelings and does not offer the immediate support she needs.
Choice C rationale
While emphasizing the health of the baby is positive, it can also be perceived as dismissive of the client's feelings and her disappointment about the birth experience.
Choice D rationale
Mentioning the resumption of sexual relations shifts the focus away from her emotional needs and can be inappropriate or insensitive in this context, failing to address her disappointment.
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