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?

Administer oxygen via nasal cannula.

Offer option to view products of conception.

Instruct the client to increase potassium-rich foods in the diet.

Maintain the client in a Trendelenburg position.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is A

Explanation

Choice A reason: Erythroblastosis fetalis is the correct answer, as it is a hemolytic disease of the newborn that occurs when the mother is Rh-negative and the newborn is Rh-positive, and the maternal antibodies cross the placenta and destroy the newborn's red blood cells, causing anemia, jaundice, and edema. Rh0 (D) immunoglobulin is an injection that prevents the formation of Rh-positive antibodies in the mother, and reduces the risk of erythroblastosis fetalis in the current or subsequent pregnancies.

Choice B reason: Hypobilirubinemia is not the correct answer, as it is a low level of bilirubin in the blood that can cause pale skin, poor feeding, or lethargy. Hypobilirubinemia is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is not a common or serious complication in the newborn.

Choice C reason: Biliary atresia is not the correct answer, as it is a congenital defect of the bile ducts that prevents the flow of bile from the liver to the intestine, causing jaundice, dark urine, and clay-colored stools. Biliary atresia is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is not a preventable complication in the newborn.

Choice D reason: Transient clotting difficulties is not the correct answer, as it is a bleeding disorder that occurs due to the deficiency of vitamin K, which is essential for the synthesis of clotting factors. Transient clotting difficulties is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is preventable by administering vitamin K to the newborn.

A. Tampons are safe to use to absorb the leaking amniotic fluid. B. Report a temperature less than 37 degrees C. C. Do not engage in sexual activity. D. Taking frequent tub baths is safe.

Correct Answer is C

Explanation

Choice A reason: Tampons are not safe to use to absorb the leaking amniotic fluid, because they can introduce bacteria into the vagina and uterus, and increase the risk of infection and preterm labor. The nurse should instruct the client to use sanitary pads instead, and change them frequently.

Choice B reason: Reporting a temperature less than 37 degrees C is not a necessary activity, because it is a normal finding and does not indicate any complication. The nurse should instruct the client to report a temperature greater than 37.8 degrees C, which can be a sign of infection or chorioamnionitis.

Choice C reason: Not engaging in sexual activity is a recommended activity, because it can help prevent further rupture of membranes, infection, and preterm labor. The nurse should instruct the client to avoid any vaginal or cervical stimulation, such as intercourse, douching, or tampon use.

Choice D reason: Taking frequent tub baths is not a safe activity, because it can expose the vagina and uterus to contaminated water, and increase the risk of infection and preterm labor. The nurse should instruct the client to take showers instead, and avoid submerging the lower body in water.

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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?

Nursing Test Bank

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