67. A client, who is 41 years old, gravida 3, para 2, is 8 weeks pregnant. She presents to an emergency department for right-sided, severe abdominal pain. Upon assessment, her temperature is 98.9°F, blood pressure is 60/40 mm Hg, pulse is 126, and respirations 22. Based on these assessment findings, a nurse should suspect that this client probably has:
. Ruptured appendix.
. Threatened spontaneous abortion.
. Ruptured ectopic pregnancy.
. Missed abortion.
Test-Taking Tip
Look at the client's vital signs; they indicate changes associated with acute blood loss. Look for the condition that involves significant blood loss.
Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because the client has a normal temperature; a fever would be present with a ruptured appendix. Answer 2 is incorrect because the client would have vaginal bleeding if she had a threatened spontaneous abortion. Answer 3 is correct because ruptured ectopic pregnancy is consistent with the assessment findings. The client has blood loss internally and her vital signs reflect shock due to hypovolemia. Advanced maternal age is a risk factor for ectopic pregnancy. Answer 4 is incorrect because a missed abortion is a fetus that has died and is retained. This client has none of the symptoms of a missed abortion.