At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

Correct Answer: C

Rationale: The client's symptoms suggest hypovolemic shock, possibly due to an ectopic pregnancy. Increasing IV fluids is crucial to stabilize the client by improving blood pressure and perfusion. This intervention helps address the underlying issue of hypovolemia and supports the client's hemodynamic status, which takes priority in this emergent situation.

Correct Answer: A

Rationale: In the scenario presented, the most significant assessment finding for a client in active labor with preeclampsia is option A) Patellar reflex 4+. This finding indicates hyperreflexia, which is a classic sign of worsening preeclampsia and impending eclampsia, a severe complication characterized by seizures. As a healthcare provider, recognizing this sign is crucial for timely intervention to prevent seizures and ensure the safety of both the mother and the baby. Option B) Blood pressure 158/80 is elevated but may not be as immediately concerning as the hyperreflexia seen in option A. Monitoring blood pressure is important in managing preeclampsia, but it is not the most significant finding in this context. Option C) Four-hour urine output 240 ml is low and indicates decreased kidney function, which is a common complication of preeclampsia. While important, it is not as urgent or directly linked to the risk of seizures as the hyperreflexia seen in option A. Option D) Respirations 12/minute is within normal range and is not specifically indicative of worsening preeclampsia. Monitoring respiratory status is important in labor, but it is not the most critical finding in the context of preeclampsia. Educationally, understanding the key assessment findings associated with preeclampsia is essential for nurses and other healthcare providers working in maternity care. Recognizing the significance of hyperreflexia in the context of preeclampsia can guide timely and appropriate interventions to prevent serious complications like eclampsia. This knowledge is crucial for providing safe and effective care to pregnant individuals experiencing complications during labor and delivery.

Correct Answer: D

Rationale: The correct GTPAL for this client is 3-1-1-0-3. G (Gravida) is 3, indicating a total of 3 pregnancies. T (Term) is 1, representing 1 full-term delivery. P (Preterm) is 1, not 2 as mentioned in the question, as twins count as one pregnancy event. A (Abortions) is 0, and L (Living) is 3, indicating 3 living children (twins count as 1). Therefore, the correct answer is 3-1-1-0-3.

Correct Answer: D

Rationale: In this scenario, option D ("They use lubricants with each sexual encounter to decrease friction") is the most likely factor impacting the couple's ability to conceive. Lubricants used during intercourse can affect sperm motility and viability, hindering the fertilization process. Educationally, it is crucial to understand the impact of external factors like lubricants on fertility. Option A (daily exercise regimen) is less likely to affect fertility unless it leads to extreme physical stress or hormonal imbalance. Option B (frequency of intercourse) is actually beneficial for conception. Option C (35-day menstrual cycle) is within the normal range and does not necessarily indicate fertility issues. It is essential for healthcare providers to educate couples on lifestyle factors that can impact fertility, such as the use of certain lubricants.

Correct Answer: B

Rationale: The correct answer is B) Screen for neural tube defects. Alpha fetoprotein (AFP) testing is a prenatal screening test that measures the levels of AFP in maternal blood to assess the risk of certain birth defects, particularly neural tube defects like spina bifida and anencephaly. Elevated AFP levels can indicate a potential problem with the developing fetus, prompting further diagnostic testing and interventions. Option A) Detect cardiovascular disorders is incorrect because AFP testing is not used to detect cardiovascular disorders. It is specifically used for screening neural tube defects. Option C) Monitor placental functioning is incorrect because AFP testing is not used to monitor placental functioning. It is primarily focused on assessing the risk of neural tube defects in the fetus. Option D) Assess for maternal pre-eclampsia is incorrect because AFP testing is not used to assess for maternal pre-eclampsia. Pre-eclampsia is a separate condition that is typically diagnosed through blood pressure monitoring and urine testing. In an educational context, it is important for healthcare providers, including LPN/LVNs, to understand the purpose and significance of prenatal screening tests like AFP testing. By accurately explaining the rationale behind the use of AFP testing for screening neural tube defects, LPN/LVNs can effectively educate expectant mothers about the importance of these tests in ensuring the health and well-being of their unborn child.