A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding.

Incomplete abortion is the initial diagnosis.

Which of the following actions should the nurse contribute to the client’s plan of care?

Administer oxygen via facemask.

Keep the client on bed rest.

Instruct the client in appropriate birth control methods.

Determine the amount and type of vaginal bleeding.

Answer and Explanation

The Correct Answer is D

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Correct Answer is C

Explanation

Choice A:
Magnesium sulfate is a medication primarily used to prevent or manage seizures in women with preeclampsia or eclampsia, conditions characterized by high blood pressure and protein in the urine during pregnancy. It is not indicated for heavy vaginal bleeding in early pregnancy.
Administration of magnesium sulfate without a clear indication could potentially lead to adverse effects such as respiratory depression, decreased deep tendon reflexes, and cardiac arrhythmias.

Choice B:
Antibiotics are used to treat bacterial infections. While heavy vaginal bleeding can sometimes be a sign of infection, it is not the primary cause of bleeding in early pregnancy.
Indiscriminate use of antibiotics without a confirmed bacterial infection can contribute to antibiotic resistance and potentially mask the underlying cause of the bleeding.

Choice D:
Cesarean birth is a major surgical procedure that is typically reserved for situations where there is a risk to the mother or fetus, such as fetal distress, failure to progress in labor, or placental abruption.
It is not indicated as the first-line intervention for heavy vaginal bleeding in early pregnancy, as there are other less invasive diagnostic and management options available.

Choice C:
A cervical examination allows the healthcare provider to assess the condition of the cervix, including its dilation and effacement, as well as to potentially identify any sources of bleeding, such as cervical polyps or lesions.
This information is crucial in determining the appropriate course of management for the patient.
It can help differentiate between potential causes of bleeding, such as threatened miscarriage, inevitable miscarriage, or ectopic pregnancy.

A. Large amount of bright red vaginal bleeding B. Severe pain with no bleeding C. High-grade fever D. Sudden sharp pain in the lower abdomen

Correct Answer is A

Explanation

Choice A rationale:
Large amount of bright red vaginal bleeding is the cardinal sign of placenta previa. This is because the placenta is abnormally positioned low in the uterus, covering the cervix partially or completely. When the cervix starts to dilate in preparation for labor, it can detach from the uterine wall, leading to significant bleeding. The blood is typically bright red, indicating fresh bleeding, and can be painless.
Severity of bleeding: The amount of bleeding can vary from spotting to massive hemorrhage, and it may start suddenly or gradually. Even a small amount of bleeding can be a sign of placenta previa and should not be ignored.
Risks of hemorrhage: Prompt recognition and management of bleeding are crucial to prevent potentially life-threatening hemorrhage for both the mother and the fetus.

Choice B rationale:
Severe pain with no bleeding is not a typical presentation of placenta previa. While some women with placenta previa may experience mild abdominal pain or cramping, severe pain without bleeding is more suggestive of placental abruption, a condition where the placenta prematurely separates from the uterine wall.

Choice C rationale:
High-grade fever is not a direct symptom of placenta previa. However, if a woman with placenta previa develops a fever, it could indicate an infection, which can further complicate the condition and require immediate medical attention.

Choice D rationale:
Sudden sharp pain in the lower abdomen can be a sign of placental abruption but is not characteristic of placenta previa.

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A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. Incomplete abortion is the initial diagnosis. Which of the following actions should the nurse contribute to the client’s plan of care?

Nursing Test Bank

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A nurse is assisting with the admission of a client who is at 8 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding.

Incomplete abortion is the initial diagnosis.

Which of the following actions should the nurse contribute to the client’s plan of care?