A nurse is caring for a client.
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Nurses' Notes
0900:
Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."
Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:
General: tearful, anxious
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant
FHR: 116/min, minimal variability noted
dark red vaginal bleeding, and abdominal pain
pain a 7 on a scale of 0 to 10
"My blood pressure has been high during the pregnancy."
Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant
116/min, minimal variability noted
bilateral breath sounds clear
tearful
The Correct Answer is ["A","B","C","D","E"]
Nurses' Notes
0900:
Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."
Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:
General: tearful, anxious
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant
FHR: 116/min, minimal variability noted
Rationale:
Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.
Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.
Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.
FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pain level of 6: Important but not life-threatening.
B. Excoriation: Requires treatment but is not the priority.
C. Xerostomia: Manageable with supportive care.
D. Dysphagia: Can lead to aspiration, malnutrition, or airway compromise and requires immediate attention.
Correct Answer is ["C","D","E","F"]
Explanation
A. Instruct the client on the use of an incentive spirometer. Although this intervention can improve lung expansion, it is not a priority in this situation, given the possibility of an airborne infectious disease and the need to address systemic and diagnostic concerns first.
B. Request a glucocorticoid prescription from the provider. While glucocorticoids may reduce inflammation, there is no immediate indication they are necessary based on the client's presentation. The priority is diagnosing and managing the underlying infection.
C. Obtain blood cultures. Blood cultures are critical to identify any systemic infection that may be contributing to the client's fever, tachycardia, and worsening symptoms. This helps guide the initiation of appropriate antimicrobial therapy.
D. Obtain a sputum culture. The client’s productive cough with blood, fever, and weight loss raise suspicion for serious respiratory infections, such as tuberculosis (TB) or other pathogens. A sputum culture is necessary to identify the causative organism for targeted treatment.
E. Recommend ABGs be drawn. The client’s oxygen saturation has dropped to 92% on room air, and there is an increase in respiratory rate, indicating possible hypoxemia or impaired gas exchange. Arterial blood gases (ABGs) provide critical information about oxygenation, ventilation, and acid-base status, guiding further interventions.
F. Place the client in a negative-pressure room. The symptoms, including a cough producing blood-tinged sputum, fever, and weight loss, are consistent with a potential diagnosis of TB or another airborne infectious disease. A negative-pressure room prevents the spread of airborne pathogens to others.
G. Administer small, frequent meals. Although the client reports a lack of appetite and weight loss, this intervention is not urgent. Addressing the client’s infection and respiratory status takes precedence.
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