A nurse is caring for a female client who is at 8 weeks of gestation in the emergency department.

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.

Answer and Explanation

The Correct Answer is []

Rationale for correct condition:
Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, typically in the fallopian tube. The absence of an intrauterine pregnancy on transvaginal ultrasound at an hCG level of 2000 IU/L (above the discriminatory zone of 1500-2000 IU/L) strongly suggests ectopic pregnancy. The patient’s left lower quadrant pain and vaginal bleeding are classic signs. Progesterone >4 ng/dL indicates a potentially viable pregnancy, but no intrauterine gestation confirms ectopic risk. Early diagnosis is crucial to prevent tubal rupture and hemorrhagic shock.

Rationale for correct actions:
Intramuscular methotrexate is a folic acid antagonist used to medically manage unruptured ectopic pregnancies by inhibiting trophoblastic cell division. It is preferred when the patient is hemodynamically stable, avoiding surgery. CBC monitors for anemia from bleeding; liver function tests assess methotrexate toxicity risk, as the drug is hepatotoxic. Both are essential for safe medical management.

Rationale for correct parameters:
Hypotension indicates potential internal bleeding from tubal rupture requiring immediate intervention. Referred shoulder pain occurs from diaphragmatic irritation by blood in the peritoneal cavity, signaling intra-abdominal hemorrhage. Monitoring these signs allows early detection of complications.

Rationale for incorrect conditions:
Spontaneous abortion typically shows declining hCG and intrauterine findings of miscarriage, which are absent here. Molar pregnancy presents with markedly elevated hCG (>100,000 IU/L) and characteristic ultrasound “snowstorm” appearance, not seen. Cervical insufficiency causes painless cervical dilation in the second trimester, not early pregnancy pain with bleeding.

Rationale for incorrect actions:
Dilation and curettage is indicated in incomplete abortion, not ectopic pregnancy. Cervical cerclage treats cervical insufficiency, unrelated to this presentation. Oxytocic agents induce uterine contractions in miscarriage or labor, not ectopic management.

Rationale for incorrect parameters:
Size of uterus is irrelevant here because no intrauterine pregnancy is seen. Uterine cramping is nonspecific and more relevant in miscarriage. Leakage of amniotic fluid occurs in membrane rupture, not ectopic pregnancy.

Take-home points:

Absence of intrauterine pregnancy at hCG >1500 IU/L suggests ectopic pregnancy.
Methotrexate is first-line medical treatment for stable ectopic pregnancies.
Hypotension and referred shoulder pain are critical signs of rupture and hemorrhage.
Differentiation from miscarriage, molar pregnancy, and cervical insufficiency is vital for appropriate care.

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Correct Answer is ["A","E"]

Explanation

Choice A rationale

Fetal heart rate assessment is paramount before administering an opioid analgesic during labor. Opioids can cross the placental barrier and cause central nervous system depression in the fetus, potentially leading to decreased fetal heart rate variability or transient decelerations. Therefore, a baseline and ongoing fetal heart rate monitoring is essential to ensure fetal well-being.

Choice B rationale

Deep tendon reflexes are primarily assessed when administering magnesium sulfate for preeclampsia, not typically before opioid analgesics. Magnesium sulfate can cause central nervous system depression and affect neuromuscular transmission, necessitating regular monitoring of deep tendon reflexes to assess for signs of toxicity. Opioids do not directly affect reflex activity in the same manner.

Choice C rationale

Blood glucose levels are not a standard assessment before administering opioid analgesics during labor. Blood glucose monitoring is crucial for clients with diabetes or gestational diabetes, or those receiving intravenous dextrose, but it is not directly related to opioid administration and its immediate effects on the mother or fetus.

Choice D rationale

Blood pressure assessment is crucial before administering an opioid analgesic because these medications can cause maternal hypotension due to their vasodilatory effects. Hypotension can reduce placental perfusion, compromising fetal oxygenation. Establishing a baseline blood pressure and monitoring it closely after administration helps ensure maternal cardiovascular stability and fetal well-being.

Choice E rationale

Pain level assessment is fundamental before administering an opioid analgesic. The primary purpose of administering an opioid is to alleviate labor pain. A thorough assessment of the intensity, location, and character of pain guides the choice, dosage, and timing of the analgesic, ensuring effective pain management and patient comfort while minimizing unnecessary medication.

A. Heart rate 132/min. B. Report of headache. C. Nasal congestion. D. Tremors.

Correct Answer is A

Explanation

Choice A rationale

Terbutaline is a beta-adrenergic agonist that can cause significant cardiovascular side effects, including tachycardia. A heart rate of 132/min is significantly elevated above the normal range (60-100/min) and indicates a potentially dangerous adverse effect, increasing myocardial oxygen demand and risk of cardiac complications.

Choice B rationale

Headache is a common side effect of terbutaline due to its vasodilatory effects. While uncomfortable, it is generally not life-threatening and is considered less urgent than significant cardiac or respiratory compromise. Management often involves supportive care and pain relief.

Choice C rationale

Nasal congestion is a less common and generally benign side effect of terbutaline. It is typically related to generalized vasodilation and does not pose a significant threat to maternal or fetal well-being, thus not being the priority for immediate reporting.

Choice D rationale

Tremors are a common and expected side effect of terbutaline due to its beta-agonist activity on skeletal muscle. While bothersome, they are typically self-limiting and do not indicate a severe adverse reaction requiring immediate reporting unless they are excessively severe or debilitating.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an opioid analgesic to a client who is in active labor. Which of the following assessments should the nurse perform?

Correct Answer is ["A","E"]

Explanation

A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?

A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain?

A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia. Which of the following actions should the nurse take?

A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit. Complete the following sentence by using the list of options. The nurse should identify that ____________ and ___________ are findings that require follow-up.

A nurse is caring for a female client who is 3 days postpartum in the postpartum unit. Which of the following actions should the nurse take?

A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy. Which of the following actions should the nurse take?

A nurse is monitoring a client who is in the active phase of labor and has an electronic fetal monitor. Which of the following findings should the nurse expect?