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A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding.
A threatened abortion is suspected, and the nurse instructs the client regarding management of care.
Which statement, if made by the client, indicates a need for further education?

A.

I will avoid sexual intercourse until the bleeding has stopped, and for two weeks following the last evidence of bleeding.

B.

I will continue with my normal life after discharge.

C.

I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad.

D.

I will watch for the evidence of the passage of tissue.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Avoiding sexual intercourse is recommended in the presence of threatened abortion to prevent further uterine irritation and potential disruption of the pregnancy. Pelvic rest helps to minimize the risk of increased bleeding or complications.

Choice B rationale

Continuing with normal life after discharge is an inappropriate statement. With a threatened abortion, the client needs to understand the importance of rest and avoiding strenuous activities that could potentially exacerbate bleeding or lead to further complications. Activities that increase intra-abdominal pressure or cause physical strain should be limited.

Choice C rationale

Counting perineal pads and noting the amount and color of blood is an important instruction for monitoring the extent of bleeding. This information helps the healthcare provider assess the progression or resolution of the threatened abortion and identify any signs of increased bleeding or passage of tissue.

Choice D rationale

Watching for the evidence of the passage of tissue is crucial as it could indicate a progressing miscarriage. The client should be instructed on how to collect any passed tissue for examination by the healthcare provider to confirm the outcome of the pregnancy. .


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Related Questions

Correct Answer is C

Explanation

Choice A rationale

Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, typically occurring in the first trimester. While amniocentesis can cause some discomfort, it is not a known risk factor for hyperemesis.

Choice B rationale

Proteinuria is the presence of protein in the urine, which can be a sign of preeclampsia, a condition that can occur later in pregnancy. Amniocentesis, usually performed in the second trimester, is not directly linked to causing proteinuria.

Choice C rationale

Amniocentesis is an invasive procedure that involves inserting a needle through the abdominal wall and uterus to withdraw amniotic fluid. This procedure carries a risk of bleeding or hemorrhage from the insertion site or within the uterus. Therefore, observing for signs of hemorrhage is a crucial nursing intervention post-amniocentesis.

Choice D rationale

Hypoxia is a condition of insufficient oxygen supply to the tissues. While complications of amniocentesis could indirectly lead to fetal hypoxia in rare cases (e.g., placental abruption), it is not a direct and common complication to observe for in the mother. Hemorrhage is a more immediate and direct risk for the mother. .

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Rationales for Each Condition

Hyperemesis Gravidarum

  1. Weight loss: Excessive vomiting leads to poor nutritional intake and dehydration, causing unintended weight loss. The normal weight gain expected in the first trimester of pregnancy is around 0.5–2 kg. A weight loss of 0.9 kg in two weeks is concerning.
  2. Hypotension: Dehydration due to persistent vomiting causes reduced intravascular volume, leading to low blood pressure. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg. The client's 96/52 mm Hg value indicates potential volume depletion.
  3. Tachycardia: Fluid loss and electrolyte imbalances increase heart rate as a compensatory mechanism to maintain perfusion. The normal heart rate ranges from 60–100 bpm, and the client's 116 bpm suggests dehydration-related tachycardia.

Cystitis

  1. Dysuria: Inflammation of the bladder due to infection causes pain or burning during urination, a classic symptom of cystitis. The absence of other urinary symptoms, such as urgency or hematuria, helps differentiate cystitis from other conditions.

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