A nurse is caring for a 30-year-old female client who is at 20 weeks of gestation in the labor and delivery unit.

Exhibits

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

Answer and Explanation

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

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Rationales for Each Condition

Hyperemesis Gravidarum

Weight loss: Excessive vomiting leads to poor nutritional intake and dehydration, causing unintended weight loss. The normal weight gain expected in the first trimester of pregnancy is around 0.5–2 kg. A weight loss of 0.9 kg in two weeks is concerning.
Hypotension: Dehydration due to persistent vomiting causes reduced intravascular volume, leading to low blood pressure. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg. The client's 96/52 mm Hg value indicates potential volume depletion.
Tachycardia: Fluid loss and electrolyte imbalances increase heart rate as a compensatory mechanism to maintain perfusion. The normal heart rate ranges from 60–100 bpm, and the client's 116 bpm suggests dehydration-related tachycardia.

Cystitis

Dysuria: Inflammation of the bladder due to infection causes pain or burning during urination, a classic symptom of cystitis. The absence of other urinary symptoms, such as urgency or hematuria, helps differentiate cystitis from other conditions.

A. Displaced fundus from the midline. B. Fundal height below the umbilicus. C. Decreased urge to void. D. Increased urine output.

Correct Answer is A

Explanation

Choice A rationale

A displaced fundus from the midline, often deviated to the right and boggy, suggests a full bladder interfering with uterine contraction and involution. A distended bladder prevents the uterus from clamping down effectively, increasing the risk of postpartum hemorrhage. Immediate intervention is required to assist the client in emptying her bladder, which should allow the uterus to return to the midline and contract firmly.

Choice B rationale

A fundal height below the umbilicus on the first postpartum day is a normal finding. Following delivery, the uterus begins to descend approximately one fingerbreadth (1 cm) per day. Therefore, a fundus below the umbilicus at 24 hours postpartum indicates normal uterine involution.

Choice C rationale

A decreased urge to void is common in the immediate postpartum period due to factors such as perineal swelling, pain, and the effects of anesthesia. While it's important to monitor urinary output, a decreased urge to void in the first 24 hours is not typically considered a finding requiring immediate intervention unless accompanied by other signs of urinary retention or bladder distension.

Choice D rationale

Increased urine output is also a normal finding in the postpartum period as the body eliminates excess fluid volume accumulated during pregnancy. Diuresis typically begins within 12 to 24 hours after delivery and can last for several days. This is a physiological process and does not require immediate intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 26-year-old female client who is at 14 weeks of gestation in the antepartum clinic. Exhibits For each assessment finding, click to specify if the finding is consistent with hyperemesis gravidarum or cystitis. Each finding may support more than one pregnancy complication.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

A nurse is performing a physical examination of a client who is 1 day postpartum.Which of the following findings requires immediate intervention?

Correct Answer is A

Explanation

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