A nurse is caring for a client who is pregnant.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for correct choices
- Hydatidiform mole: The client’s findings are consistent with a molar pregnancy. Key indicators include an intrauterine mass with cystic vesicles on ultrasound, absence of a fetus, elevated fundal height (28 cm at approximately 4 months gestation), and symptoms such as nausea/vomiting and dark brown vaginal discharge. Elevated blood pressure and anemia further support this diagnosis due to trophoblastic disease.
- Prepare the client for suction curettage: Suction curettage (D&C) is the primary treatment to evacuate abnormal trophoblastic tissue from the uterus. It helps prevent complications such as hemorrhage and progression to gestational trophoblastic neoplasia.
- Discuss weekly pregnancy hormone level monitoring: Serial monitoring of human chorionic gonadotropin (hCG) levels is essential to ensure complete resolution of trophoblastic tissue and to detect persistent disease or malignancy early.
- Vaginal bleeding: Bleeding is a common complication due to abnormal placental tissue and uterine evacuation. Monitoring helps detect hemorrhage or retained products.
- Blood pressure: Hypertension can occur with molar pregnancy due to excessive hCG levels and trophoblastic proliferation; monitoring helps detect complications such as preeclampsia-like symptoms.
Rationale for incorrect choices
- Ectopic pregnancy: This typically presents with unilateral pelvic pain and absence of intrauterine pregnancy on ultrasound, not a uterine mass with cystic vesicles.
- Abruptio placentae: Would present with painful vaginal bleeding and a tender, rigid uterus in later pregnancy, not cystic vesicles or absent fetus.
- Placenta previa: Characterized by painless bright red bleeding and a low-lying placenta, not uterine mass or elevated fundal height discrepancies.
- Prepare the client for an emergency cesarean birth: There is no viable fetus present, and ultrasound confirms absence of fetal structures.
- Administer terbutaline: Used for uterine relaxation in preterm labor, which is not applicable here.
- Cervical dilation: Not a key indicator in molar pregnancy; cervix is not the primary focus of pathology.
- Uterus for hypertonicity: Not typical; the uterus may be enlarged but not characteristically hypertonic.
- Unilateral pelvic pain: More consistent with ectopic pregnancy, not molar pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A mild sore throat is a common expected finding after an EGD due to insertion of the endoscope through the oropharynx and esophagus. It usually resolves without intervention. Only severe pain, bleeding, or difficulty swallowing would require further evaluation.
B. Clients are typically instructed to remain NPO (nothing by mouth) for 6–8 hours before an EGD to ensure an empty stomach. This reduces the risk of aspiration during sedation and scope insertion.
C. Clients receive sedative medications during an EGD, which impair judgment, reflexes, and coordination. They should not drive, operate machinery, or make important decisions for the remainder of the day. They must have a responsible adult accompany them home.
D. After an EGD, local anesthetic (such as lidocaine spray) is often used to suppress the gag reflex. The nurse must assess the return of the gag reflex before allowing oral intake to prevent aspiration. This is a key safety step in post-procedure care.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Excess body weight increases intra-abdominal pressure, which places additional stress on the bladder and pelvic floor muscles. This can worsen stress incontinence. Weight management is an important nonpharmacological intervention to reduce urine leakage episodes.
B. Fluid restriction is not recommended for stress incontinence and may lead to dehydration, concentrated urine, and urinary tract irritation. Normal adequate hydration is encouraged unless otherwise contraindicated.
C. Pelvic floor muscle (Kegel) exercises strengthen the muscles that support the urethra and bladder neck, improving sphincter control and reducing urine leakage during activities such as coughing, sneezing, or lifting.
D. Timed voiding or bladder training helps reduce episodes of incontinence by emptying the bladder regularly and preventing unexpected leakage. It helps the client regain better bladder control over time.
E. While timing diuretics earlier in the day can reduce nocturia, diuretics are not a primary treatment for stress incontinence and may actually worsen urinary frequency and leakage if not appropriately indicated. They are not a standard teaching point for stress incontinence management.
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