A nurse is caring for a client at the clinic.
Complete the following sentence by using the lists of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Rationale for correct choices
• Spontaneous abortion: The client is presenting at 10 weeks gestation with moderate, bright red vaginal bleeding and a history of risk factors including type 1 diabetes mellitus and recurrent infections. The open cervix on examination indicates that the pregnancy may not be viable and suggests impending or ongoing miscarriage.
• Cervical dilation: Cervical dilation is a key clinical sign of spontaneous abortion, as it indicates that the body is preparing to expel the pregnancy. The presence of an open cervix in conjunction with vaginal bleeding and cramping directly supports the risk for miscarriage. Monitoring cervical changes helps the healthcare team assess the progression and urgency of intervention.
Rationale for incorrect choices
• Molar pregnancy: Molar pregnancy typically presents with markedly elevated hCG levels, larger-than-expected uterine size, and absence of a viable embryo. Although the client has an elevated hCG, the level is not excessively high, and there is no indication of vesicular tissue or characteristic ultrasound findings, making molar pregnancy unlikely.
• Ectopic pregnancy: Ectopic pregnancy generally presents with unilateral abdominal pain, shoulder pain, and sometimes hypotension or signs of internal bleeding. The client’s bleeding is bright red, moderate, and accompanied by cervical dilation, which is not typical for an ectopic pregnancy. No abdominal mass or unilateral tenderness is reported, reducing the likelihood of this diagnosis.
• Lower abdominal cramping: While cramping is a symptom associated with miscarriage, it alone is not sufficient evidence to determine the risk for spontaneous abortion. Cervical dilation is a more definitive clinical sign indicating that the miscarriage may be occurring or imminent.
• hCG levels: The client’s hCG level of 30,000 IU/L is within the expected range for 10 weeks gestation and does not specifically indicate miscarriage. Unlike cervical dilation, hCG levels alone cannot confirm the risk for spontaneous abortion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Keep the foot in plantar flexion: Maintaining the foot in plantar flexion increases the risk of developing foot drop by shortening the dorsiflexor muscles. This position does not support proper alignment or prevent contractures, making it counterproductive for prevention.
B. Elevate the client's feet on pillows: Elevating the feet may help reduce edema but does not prevent foot drop. It does not maintain proper dorsiflexion or support the ankle in a neutral position, so it is not effective for contracture prevention.
C. Brace the foot with an ankle-foot orthotic: An ankle-foot orthotic maintains the foot in a neutral position, preventing plantar flexion contractures and promoting proper alignment of the ankle. This intervention is highly effective for preventing foot drop in immobile clients by keeping the muscles and tendons stretched appropriately.
D. Perform passive range of motion of the ankle twice per day: Passive range of motion helps maintain joint mobility and circulation but alone may be insufficient to prevent foot drop. Consistent bracing or positioning is necessary to maintain neutral alignment when the client is not actively moving the ankle.
Correct Answer is A
Explanation
Rationale:
A. "I will change my baby's diaper at least every 4 hours.": Frequent diaper changes help keep the circumcision site clean and dry, reducing the risk of infection and irritation from urine or stool. Keeping the area free from moisture allows proper healing and minimizes discomfort for the newborn. This reflects correct home care following a circumcision.
B. "I will wash the penis with soap and warm water until the circumcision has healed.": Using soap on the circumcision site can cause irritation and delay healing. The area should be gently cleansed with warm water only, allowing the natural healing process to occur without additional chemical irritation from soaps or wipes containing alcohol or fragrances.
C. "I will apply topical lidocaine following each diaper change.": Topical anesthetics such as lidocaine are not recommended for routine circumcision care because they may cause toxicity or be absorbed unpredictably in newborns. Pain is managed through comfort measures such as swaddling, breastfeeding, or using petroleum jelly, not through anesthetic application.
D. "I will apply an ice pack to my baby's penis twice daily to decrease swelling.": Applying ice to a newborn’s circumcision site is unsafe and can cause tissue injury due to extreme temperature sensitivity. Mild swelling is expected and resolves naturally; the recommended care involves gentle cleansing and protecting the site with petroleum jelly not cold therapy.
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