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 D
Explanation
Choice A rationale:
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
Choice B rationale:
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.
Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
Choice C rationale:
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.
Correct Answer is B
Explanation
Choice A rationale:
The nurse should not measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr because this action does not address the specific problem presented in the scenario, which is abdominal distention and bloody stools. Measuring abdominal circumference is typically done to assess for growth and may not provide valuable information in this situation.
Choice B rationale:
Inserting an orogastric decompression tube with low wall suction is the appropriate action for a newborn with abdominal distension and bloody stools. This intervention can help decompress the gastrointestinal tract, reducing abdominal distention, and possibly preventing further complications.
Choice C rationale:
Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated based on the information provided in the scenario. The newborn's symptoms are suggestive of gastrointestinal issues, and this intervention may not address the underlying cause.
Choice D rationale:
Administering nitric oxide inhalation therapy to the newborn is not appropriate in this context. Nitric oxide inhalation therapy is typically used for conditions like persistent pulmonary hypertension in the newborn, and there is no indication for its use in this case.
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