A nurse is caring for a 30-year-old female client who is at 20 weeks of gestation in the labor and delivery unit.
For each of the listed client findings, click to specify if the finding is consistent with ectopic pregnancy or molar pregnancy. Each finding may support more than 1 disease process.
Client report of abdominal pain
Blood pressure
Ultrasound results
Perineal pad findings
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"}}
Rationales for Each Condition
Molar Pregnancy
- Abdominal Pain: In a molar pregnancy, the uterus enlarges disproportionately due to abnormal trophoblastic growth. This excessive expansion can cause discomfort or mild cramping.
- Blood Pressure: Molar pregnancies can be associated with gestational trophoblastic disease, which may lead to preeclampsia-like symptoms. However, this client’s blood pressure is currently within normal limits (120/78 mm Hg), so severe hypertension has not yet developed.
- Ultrasound Findings: The presence of grape-like vesicles within the uterus and the absence of a fetal heartbeat are hallmark findings of a molar pregnancy, indicating abnormal placental tissue proliferation.
- Perineal Pad Findings: The passage of small clear vesicles is a characteristic feature of a molar pregnancy, distinguishing it from other causes of vaginal bleeding in pregnancy.
Ectopic Pregnancy
- Abdominal Pain: Ectopic pregnancies often cause sharp lower abdominal pain due to tubal rupture or irritation. However, in this case, the client’s pain is mild and less suggestive of tubal rupture.
- Blood Pressure: If an ectopic pregnancy ruptures, hypotension due to internal bleeding would be expected. Since the client’s blood pressure is normal, this finding does not support an ectopic pregnancy.
- Ultrasound Findings: The absence of a fetal heartbeat and vesicular structures inside the uterus make ectopic pregnancy unlikely, as ectopic pregnancies typically occur in the fallopian tube.
- Perineal Pad Findings: Ectopic pregnancies rarely cause the passage of vesicular tissue, further suggesting that this is not an ectopic pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying heat to the breasts in mastitis can increase blood flow and potentially worsen inflammation. While heat can be comforting for engorgement, in mastitis, it may exacerbate the inflammatory response and should be used cautiously or avoided in the acute phase. The primary goal is to remove milk and reduce inflammation.
Choice B rationale
Removing the nursing bra might provide some temporary comfort if the bra is too tight and constricting milk flow. However, it does not address the underlying infection or inflammation of mastitis. Supportive nursing bras are generally recommended to provide support without restricting milk ducts.
Choice C rationale
Given the early indications of mastitis, such as a hard, warm area in the breast, moderate lochia rubra (which is normal for postpartum day 3), and a fundus appropriately descended, additional interventions are indeed indicated to prevent the progression of the infection and promote healing. Ignoring these signs could lead to a more severe infection.
Choice D rationale
Continued breastfeeding is crucial for managing mastitis. Frequent emptying of the breasts helps to remove the stagnant milk, which can contribute to the infection. Breast milk has antimicrobial properties that can aid in resolving the infection. Encouraging the client to breastfeed frequently on the affected side, starting with that side, promotes drainage and healing.
Correct Answer is B
Explanation
Choice A rationale
A glucose reading of 58 mg/dL in a newborn is below the normal range (typically 40-60 mg/dL in the first hours of life, rising to 50-90 mg/dL). While this requires intervention to prevent hypoglycemia, other parameters might indicate a more immediate threat to the newborn's well-being.
Choice B rationale
A temperature of 97.4°F (36.3°C) is below the normal range for a newborn (typically 97.7°F to 99.5°F or 36.5°C to 37.5°C). Hypothermia in a newborn can lead to cold stress, increasing oxygen and glucose consumption, potentially leading to respiratory distress and hypoglycemia. Therefore, a low temperature requires immediate assessment and intervention to warm the newborn.
Choice C rationale
A respiratory rate of 48 breaths/minute is within the normal range for a newborn (typically 30-60 breaths/minute). While the respiratory rate should be monitored, it does not indicate an immediate critical issue in this case.
Choice D rationale
A pulse of 134 beats/minute is within the normal range for a newborn (typically 110-160 beats/minute). While the heart rate should be monitored, it does not indicate an immediate critical issue in this case. .
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