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 B

Explanation

Choice A rationale

A positive pregnancy test detects the presence of human chorionic gonadotropin (hCG) in urine or blood. While highly suggestive, it is classified as a probable sign because certain conditions other than pregnancy can elevate hCG levels, although these are rare, making it not definitively diagnostic.

Choice B rationale

Amenorrhea, the cessation of menstruation, is a common early indicator of pregnancy due to hormonal changes, specifically rising progesterone levels that inhibit follicular development and uterine shedding. However, various factors unrelated to pregnancy, such as stress or hormonal imbalances, can also cause amenorrhea, categorizing it as a presumptive sign.

Choice C rationale

Fetal heart sounds, when auscultated, are a definitive sign of pregnancy because they directly confirm the presence of a viable fetus. This auditory confirmation is unambiguous and cannot be attributed to any other condition, making it a positive sign of pregnancy.

Choice D rationale

Chadwick sign refers to the bluish-purple discoloration of the cervix, vagina, and labia due to increased vascularity and blood flow, typically observed around 6-8 weeks of gestation. While highly indicative of pregnancy, it is considered a probable sign because other conditions can also cause pelvic congestion, although less commonly.

A. Cool the newborn's heel prior to the procedure. B. Puncture the center of the newborn's heel. C. Cleanse the puncture site with alcohol gauze prior to the procedure. D. Administer vitamin K 30 min prior to each blood draw.

Correct Answer is C

Explanation

Choice A rationale

Cooling the newborn's heel causes vasoconstriction, which reduces blood flow to the area. This would make it more difficult to obtain an adequate blood sample and could lead to repeated punctures, increasing the risk of discomfort and tissue damage for the newborn. Optimal blood flow is crucial for a successful heel stick.

Choice B rationale

Puncturing the center of the newborn's heel risks damaging the calcaneus bone, which can lead to osteomyelitis, an infection of the bone. The proper technique involves puncturing the lateral aspects of the heel to avoid bone injury and ensure patient safety.

Choice C rationale

Cleansing the puncture site with an alcohol gauze pad prior to the procedure is essential for asepsis. Alcohol acts as an antiseptic by denaturing proteins and dissolving lipids in bacterial cell membranes, effectively reducing the microbial load on the skin surface and minimizing the risk of introducing pathogens into the bloodstream during the puncture.

Choice D rationale

Administering vitamin K is typically done shortly after birth to prevent hemorrhagic disease of the newborn, as newborns have immature livers and insufficient gut flora for vitamin K synthesis. It is not routinely administered 30 minutes prior to every blood draw and is unrelated to the immediate procedure of obtaining a heel stick sample.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy?

Correct Answer is B

Explanation

A nurse is planning to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who has preeclampsia and received a dose of calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?

A nurse is assessing a 1-hour-old newborn. Which of the following findings should the nurse report to the provider?

A nurse is assessing a client who is 6 hours postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?

A nurse is teaching a client about iron supplementation during pregnancy. Which of the following client statements indicates an understanding of the teaching?

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?

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?

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 caring for a female client following an emergency cesarean birth in the postpartum unit. Based on the 0715 assessment findings, the nurse identifies that the client is at greatest risk for developing _________ and ________.