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?

Initiate an IV infusion of magnesium sulfate.

Administer antibiotics.

Request the RN perform a cervical examination.

Prepare for cesarean birth.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is A

Explanation

Choice A rationale:
Quickening is the term used to describe the first noticeable fetal movements felt by the pregnant person. It is often described as a fluttering or bubbling sensation in the lower abdomen.
Quickening typically occurs between 16 and 22 weeks of gestation, with an average of 18 weeks. It is a normal and reassuring sign that the pregnancy is progressing well.
The sensation of quickening is caused by the fetus moving its arms and legs, as well as by its body turning and rotating within the amniotic fluid.
It is important to note that not all pregnant women experience quickening at the same time, and some women may not feel it at all.
However, in this case, the client is at 16 weeks of gestation, which is within the typical timeframe for quickening to occur. Moreover, the client's description of "light fluttering in her stomach" is consistent with the sensation of quickening.

Choice B rationale:
Lightening is the term used to describe the descent of the fetus into the pelvis in preparation for labor.
It typically occurs in the last few weeks of pregnancy, and is often accompanied by a feeling of increased pressure in the pelvis and bladder.
The client in this question is only at 16 weeks of gestation, so it is too early for lightening to have occurred.

Choice C rationale:
Braxton Hicks contractions are irregular, painless contractions of the uterus that can occur throughout pregnancy.
They are often described as a tightening or hardening of the uterus, and they may come and go over a period of several hours. Braxton Hicks contractions are not a sign of labor, but they can sometimes be mistaken for it.
The client in this question did not describe any contractions, so Braxton Hicks contractions are not a likely explanation for her symptoms.

Choice D rationale:
Chloasma is a skin condition that is characterized by brown patches on the face.
It is also known as the "mask of pregnancy" because it is more common in pregnant women. Chloasma is caused by hormonal changes during pregnancy, and it typically fades after delivery.
The client in this question did not describe any skin changes, so chloasma is not a likely explanation for her symptoms

A. Negative test. B. Positive test. C. Reactive test. D. Non-reactive deceleration of rising in the fetal heart rate during a period.

Correct Answer is C

Explanation

Choice A rationale:

A negative test implies a non-reactive NST, meaning the fetal heart rate (FHR) did not demonstrate the expected accelerations in response to fetal movements.

However, the scenario states that fetal movements were noted, and decelerations were observed. Decelerations, even lasting 30 seconds, are not consistent with a negative test.

Choice B rationale:

A positive test is not a standard term used in the context of NST results.

The term "positive" is more often associated with tests that identify a specific condition or abnormality.

NST results are typically classified as reactive or non-reactive, with further interpretation based on the presence or absence of decelerations and other FHR patterns.

Choice C rationale:

A reactive NST is the desired outcome, indicating a healthy fetal response to movement.

It requires two or more FHR accelerations of at least 15 beats per minute for a minimum of 15 seconds, each within a 20- minute period.

Although the decelerations lasting 30 seconds warrant further assessment, they do not negate the presence of the required accelerations, making the test reactive.

Choice D rationale:

"Non-reactive deceleration of rising in the fetal heart rate during a period" is not a standard NST result terminology.

It incorrectly combines elements of non-reactivity (lack of accelerations) with a description of decelerations, which are distinct FHR patterns.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is at 16 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the prior day. The nurse should use which of the following terms to document this finding?

Correct Answer is A

Explanation

A nurse caring for a client during a non-stress test (NST) notes fetal movement. Each deceleration lasts 30 seconds. Which of the following results are in?

Correct Answer is C

Explanation

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