Explanation/Reference:
Explanation:
(A) This symptom would indicate a rupture of the membranes, which would be expected during labor.
There would be no cause for alarm if the fluid were clear. (B) With uterine rupture and the risk of maternal shock secondary to blood loss, the most likely sign would be hypotension indicating hypovolemic shock.
(C) In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness.
(D) The most likely finding would be a decrease in fetal movement related to fetal distress due to impaired uteroplacental blood flow. Maintaining the client on her left side would help to maximize uterine blood flow.

Section: Questions Set A
Explanation:
(A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds a represent because of the increased anteroposterior chest diameter. (C) A barrel-shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.

Explanation
(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.

Explanation/Reference:
Explanation:
(A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying.

Section: Questions Set G
Explanation:
(A) Analgesic medication does not counteract the effects of antibiotics. (B) Analgesic medication may lower blood pressure elevated due to anxiety. (C) Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be apparent. Also, further depression of the CNS is contraindicated. (D) Analgesics do not stimulate the CNS.