Nokea
The nurse is assessing a pregnant client with a diagnosis of abruptio placentae. Which manifestations of this condition should the nurse expect to note? Select all that apply.
- A. Uterine irritability
- B. Uterine tenderness
- C. Painless vaginal bleeding
- D. Abdominal and low back pain
- E. Strong and frequent contractions
- F. Nonreassuring fetal heart rate patterns
Correct Answer: A,B,D,F
Rationale: Placental abruption, also referred to as abruptio placentae, is the separation of a normally implanted placenta before the fetus is born. It occurs when there is bleeding and formation of a hematoma on the maternal side of the placenta. Manifestations include uterine irritability with frequent low-intensity contractions, uterine tenderness that may be localized to the site of the abruption, aching and dull abdominal and low back pain, painful vaginal bleeding, and a high uterine resting tone identified by the use of an intrauterine pressure catheter. Additional signs include nonreassuring fetal heart rate patterns, signs of hypovolemic shock, and fetal death. Painless vaginal bleeding is a sign of placenta previa.
You may also like to solve these questions
While gathering data, the nurse notes that the client has been prescribed tolterodine tartrate. The nurse should determine that the client is taking the medication to treat which disorder?
- A. Glaucoma
- B. Pyloric stenosis
- C. Renal insufficiency
- D. Urinary frequency and urgency
Correct Answer: D
Rationale: Tolterodine tartrate is an antispasmodic used to treat overactive bladder and symptoms of urinary frequency, urgency, or urge incontinence. It is contraindicated in urinary retention and uncontrolled narrow-angle glaucoma. It is used with caution in renal function impairment, bladder outflow obstruction, and gastrointestinal obstructive disease such as pyloric stenosis.
A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. Which expected prescription should the nurse immediately implement for this client? Select all that apply.
- A. Supplemental oxygen
- B. High Fowler's position
- C. Semi-Fowler's position
- D. Morphine sulfate intravenously
- E. Two tablets of acetaminophen with codeine
- F. Meperidine hydrochloride intravenously
Correct Answer: A,C,D
Rationale: Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.
The nurse is preparing to measure the fundal height of a client whose fetus is 28 weeks' gestation. In what position should the nurse place the client to perform the procedure?
- A. In a standing position
- B. In the Trendelenburg position
- C. Supine with the head of the bed elevated to 45 degrees
- D. Supine with her head on a pillow and knees slightly flexed
Correct Answer: D
Rationale: When measuring fundal height, the client lies in a supine (back) position with her head on a pillow and knees slightly flexed. The standing position, Trendelenburg (head lowered), or supine with the head of the bed elevated to 45 degrees would prevent the nurse from getting an accurate measurement.
A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation?
- A. Weight loss
- B. Bilateral crackles
- C. Distended neck veins
- D. Peripheral pitting edema
Correct Answer: B
Rationale: The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.
The nurse caring for a client receiving intravenous therapy monitors for which signs of infiltration of an intravenous (IV) infusion? Select all that apply.
- A. Slowing of the IV rate
- B. Tenderness at the insertion site
- C. Edema around the insertion site
- D. Skin tightness at the insertion site
- E. Warmth of skin at the insertion site
- F. Fluid leaking from the insertion site
Correct Answer: A,B,C,D,F
Rationale: Infiltration is the leakage of an IV solution into the extravascular tissue. Manifestations include slowing of the IV rate; burning, tenderness, or general discomfort at the insertion site; increasing edema in or around the catheter insertion site; complaints of skin tightness; blanching or coolness of the skin; and fluid leaking from the insertion site.