A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?
Scant, bright red spotting.
Elevated hCG.
Cervical dilation.
Slight abdominal cramps.
The Correct Answer is C
Choice A rationale:
Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.
Choice B rationale:
Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.
Choice C rationale:
Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.
Choice D rationale:
Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Single palmar creases.
Choice A rationale:
Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
Choice B rationale:
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
Choice C rationale:
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
Choice D rationale:
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
Correct Answer is A
Explanation
The correct answer is choice A, administer broad-spectrum antibiotics.
Choice A rationale:
Administering broad-spectrum antibiotics is crucial for a newborn with a myelomeningocele that is leaking cerebrospinal fluid to prevent infection. The leaking of cerebrospinal fluid can increase the risk of meningitis, which is an infection of the membranes covering the brain and spinal cord. Broad-spectrum antibiotics are used as a prophylactic measure to reduce this risk.
Choice B rationale:
Monitoring the rectal temperature every 4 hours is important for detecting fever, which could indicate infection. However, it is not the most immediate action required for a newborn with a leaking myelomeningocele. The priority is to prevent infection through the administration of antibiotics.
Choice C rationale:
Cleansing the site with povidone-iodine is not recommended for a myelomeningocele because it can be toxic to the exposed neural tissue. Instead, the area should be covered with a sterile saline dressing to protect the site and prevent drying and further damage to the neural tissue.
Choice D rationale:
While surgical closure is necessary for a newborn with myelomeningocele, it is typically performed within 24 to 48 hours after birth, not after 72 hours. Early closure is essential to reduce the risk of infection and further damage to the exposed spinal cord and nerves.
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