A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

Uterine enlargement greater than expected for gestational age

Unilateral, cramp-like abdominal pain

Severe nausea and vomiting

Large amount of vaginal bleeding

Answer and Explanation

The Correct Answer is B

Choice A reason: Uterine enlargement greater than expected for gestational age is not a typical manifestation of ectopic pregnancy, because the embryo is implanted outside the uterus, usually in the fallopian tube. The uterus may be slightly enlarged due to hormonal changes, but not more than expected for the gestational age.

Choice B reason: Unilateral, cramp-like abdominal pain is a common manifestation of ectopic pregnancy, because the embryo grows and stretches the fallopian tube, causing inflammation and irritation. The pain may be mild or severe, depending on the size and location of the ectopic pregnancy, and may radiate to the shoulder or back.

Choice C reason: Severe nausea and vomiting is not a specific manifestation of ectopic pregnancy, because it can be caused by other conditions, such as hyperemesis gravidarum, gastroenteritis, or appendicitis. The client may have mild nausea and vomiting due to hormonal changes, but not more than usual for the gestational age.

Choice D reason: Large amount of vaginal bleeding is not a usual manifestation of ectopic pregnancy, because the bleeding is usually internal, into the abdominal cavity. The client may have spotting or light bleeding due to the detachment of the endometrium, but not heavy or profuse bleeding.

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Correct Answer is B

Explanation

Choice A reason: Administering oxygen via nasal cannula is not a necessary intervention for the client, unless she has signs of hypoxia, such as dyspnea, tachypnea, or cyanosis. Oxygen administration is not routinely indicated for clients with inevitable abortion.

Choice B reason: Offering option to view products of conception is an appropriate intervention for the client, because it can help her cope with the loss of pregnancy and facilitate the grieving process. The nurse should respect the client's decision and provide emotional support.

Choice C reason: Instructing the client to increase potassium-rich foods in the diet is not a relevant intervention for the client, unless she has signs of hypokalemia, such as muscle weakness, cramps, or arrhythmias. Potassium intake is not related to the cause or prevention of inevitable abortion.

Choice D reason: Maintaining the client in a Trendelenburg position is not a recommended intervention for the client, because it can increase the risk of aspiration, respiratory compromise, and venous congestion. Trendelenburg position is not effective in preventing or treating inevitable abortion.

A. Insert a gloved hand into the vagina to relieve pressure on the cord. B. Cover the cord with a sterile, moist saline dressing. C. Place the client in knee-chest position. D. Prepare the client for an immediate birth.

Correct Answer is A

Explanation

Choice A reason: This action is the first and most important intervention that the nurse should perform, as it can prevent or reduce the compression of the umbilical cord, which can cause fetal hypoxia, bradycardia, or death. The nurse should insert a gloved hand into the vagina and gently push the presenting part away from the cord, and maintain this position until the delivery.

Choice B reason: This action is not the first intervention that the nurse should perform, as it does not address the cause of the cord prolapse, which is the displacement of the cord below the presenting part. However, this action is helpful to prevent the drying and infection of the cord, and should be done after the first intervention.

Choice C reason: This action is not the first intervention that the nurse should perform, as it may not be effective or feasible depending on the stage of labor and the client's condition. However, this action is beneficial to reduce the pressure of the presenting part on the cord, and should be done after the first intervention.

Choice D reason: This action is not the first intervention that the nurse should perform, as it does not provide immediate relief or protection to the fetus. However, this action is necessary to expedite the delivery and prevent further complications, and should be done after the first intervention.

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A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

Correct Answer is A

Explanation

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