A client at 6-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the nurse take?
Check serum human chorionic gonadotropin.
Verify the date of the last menstrual cycle.
Inquire about the last occurrence of intercourse.
Repeat a urine pregnancy test.
The Correct Answer is A
Choice A rationale
Checking serum human chorionic gonadotropin (hCG) levels is the appropriate action. hCG levels can help determine the viability of the pregnancy. Decreasing hCG levels may indicate a non-viable pregnancy, while increasing levels suggest a viable pregnancy.
Choice B rationale
Verifying the date of the last menstrual cycle is important but not the priority action in this scenario. While it can provide information on gestational age, it does not directly address the concern of vaginal bleeding.
Choice C rationale
Inquiring about the last occurrence of intercourse is not directly related to assessing the cause of vaginal bleeding. It may provide additional history but does not address the immediate concern.
Choice D rationale
Repeating a urine pregnancy test is not necessary in this context. The client is already known to be pregnant, and a urine test will not provide additional information regarding the cause of the bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.
Choice B rationale
Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.
Choice C rationale
Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.
Choice D rationale
Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Breast milk contains antibodies, specifically Immunoglobulin A (IgA), which provide passive immunity to infants and help in fighting off infections. This protective mechanism is especially important in the early months when the infant's immune system is still developing.
Choice B rationale
The immune system of a newborn is immature, particularly in its ability to produce its own antibodies. This immaturity means that newborns rely on passive immunity from the mother, either through the placenta during pregnancy or via breast milk after birth.
Choice C rationale
Infants possess passive immunity during the first few months of life, derived from maternal antibodies transferred through the placenta. This temporary immunity provides a crucial defense against infections until the infant's own immune system becomes more developed and capable of responding to pathogens.
Choice D rationale
While newborns have some level of immune function, it is not fully developed within the first month of life. Active immunity, the body's ability to produce its own antibodies in response to pathogens, takes several months to fully mature. .
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