A nurse is admitting a client who is at 39 weeks of gestation and in active labor.
The client reports being positive for group B streptococcus (GBS) when screened at 36 weeks of gestation. Which of the following actions should the nurse expect to take?

Rationale for correct condition:
Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, typically in the fallopian tube. The absence of an intrauterine pregnancy on transvaginal ultrasound at an hCG level of 2000 IU/L (above the discriminatory zone of 1500-2000 IU/L) strongly suggests ectopic pregnancy. The patient’s left lower quadrant pain and vaginal bleeding are classic signs. Progesterone >4 ng/dL indicates a potentially viable pregnancy, but no intrauterine gestation confirms ectopic risk. Early diagnosis is crucial to prevent tubal rupture and hemorrhagic shock.

Rationale for correct actions:
Intramuscular methotrexate is a folic acid antagonist used to medically manage unruptured ectopic pregnancies by inhibiting trophoblastic cell division. It is preferred when the patient is hemodynamically stable, avoiding surgery. CBC monitors for anemia from bleeding; liver function tests assess methotrexate toxicity risk, as the drug is hepatotoxic. Both are essential for safe medical management.

Rationale for correct parameters:
Hypotension indicates potential internal bleeding from tubal rupture requiring immediate intervention. Referred shoulder pain occurs from diaphragmatic irritation by blood in the peritoneal cavity, signaling intra-abdominal hemorrhage. Monitoring these signs allows early detection of complications.

Rationale for incorrect conditions:
Spontaneous abortion typically shows declining hCG and intrauterine findings of miscarriage, which are absent here. Molar pregnancy presents with markedly elevated hCG (>100,000 IU/L) and characteristic ultrasound “snowstorm” appearance, not seen. Cervical insufficiency causes painless cervical dilation in the second trimester, not early pregnancy pain with bleeding.

Rationale for incorrect actions:
Dilation and curettage is indicated in incomplete abortion, not ectopic pregnancy. Cervical cerclage treats cervical insufficiency, unrelated to this presentation. Oxytocic agents induce uterine contractions in miscarriage or labor, not ectopic management.

Rationale for incorrect parameters:
Size of uterus is irrelevant here because no intrauterine pregnancy is seen. Uterine cramping is nonspecific and more relevant in miscarriage. Leakage of amniotic fluid occurs in membrane rupture, not ectopic pregnancy.

Take-home points:

• Absence of intrauterine pregnancy at hCG >1500 IU/L suggests ectopic pregnancy.
• Methotrexate is first-line medical treatment for stable ectopic pregnancies.
• Hypotension and referred shoulder pain are critical signs of rupture and hemorrhage.
• Differentiation from miscarriage, molar pregnancy, and cervical insufficiency is vital for appropriate care.

Choice A rationale

Wound infection following circumcision typically presents with signs such as erythema (redness), localized warmth, purulent drainage, and swelling, often accompanied by fever. Yellow exudate alone, without these other inflammatory indicators, does not align with the typical presentation of a bacterial infection.

Choice B rationale

Ulceration would manifest as an open sore or a break in the skin integrity, often with raw, exposed tissue. The yellow exudate covering the glans, if it represents a healing process, is a protective layer and not indicative of tissue breakdown or an open ulcer.

Choice C rationale

Exposure to urine does not typically result in a uniform yellow exudate covering the glans. While prolonged urine exposure can lead to skin irritation or maceration, the described finding is a distinct physiological response associated with tissue repair rather than simple urinary contact.

Choice D rationale

The formation of a yellow exudate or "scab" on the glans penis is a normal physiological response during the healing process after circumcision. This fibrinogen-rich layer acts as a protective barrier, preventing infection and facilitating re-epithelialization of the wound, and it typically resolves within 7-10 days.