A woman is recovering at the gynecologist's office following a first trimester spontaneous abortion. At this time, it is essential for the nurse to check which of the following?
Maternal blood type
Past obstetric history
Maternal varicella titer
Cervical patency
The Correct Answer is A
Choice A) Maternal blood type is correct because this is an essential and relevant information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Spontaneous abortion, also known as miscarriage, is the loss of pregnancy before 20 weeks of gestation. It can be caused by various factors such as chromosomal abnormalities, infections, trauma, or hormonal imbalances. Maternal blood type is the classification of blood based on the presence or absence of antigens and antibodies on the red blood cells and plasma. The most common blood types are A, B, AB, and O, and each can be positive or negative for the Rh factor. Checking maternal blood type can help to identify and prevent Rh incompatibility, which is a condition that occurs when the mother has Rh-negative blood and the fetus has Rh-positive blood. This can cause the mother's immune system to produce antibodies that attack the fetal red blood cells, leading to hemolytic disease of the fetus and newborn (HDFN), which can cause anemia, jaundice, or death. To prevent this, the nurse should administer Rh immunoglobulin (RhoGAM) to the mother within 72 hours after a spontaneous abortion or any event that may cause mixing of maternal and fetal blood. Therefore, this information is vital and appropriate for the nurse to check.
Choice B) Past obstetric history is incorrect because this is not an essential or urgent information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Past obstetric history is the record of previous pregnancies and their outcomes, such as number, duration, complications, or interventions. It can provide useful information for assessing the risk factors and health status of the current pregnancy. However, it does not have any immediate impact or implication for the management of a spontaneous abortion, which is a common and unpredictable event that affects about 10% to 20% of all pregnancies. Therefore, this information can be obtained later or from other sources by the nurse.
Choice C) Maternal varicella titer is incorrect because this is not a relevant or necessary information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Varicella titer is a blood test that measures the level of antibodies against varicella-zoster virus (VZV), which causes chickenpox and shingles. It can indicate whether a person has immunity to VZV or needs vaccination. Checking maternal varicella titer may be important for pregnant women who have not had chickenpox or vaccination before, as VZV infection during pregnancy can cause congenital varicella syndrome (CVS), which can affect the development and function of various organs in the fetus. However, it does not relate to spontaneous abortion, which is not caused by VZV infection or immunity. Therefore, this information is irrelevant and unnecessary for the nurse to check.
Choice D) Cervical patency is incorrect because this is not a reliable or accurate information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Cervical patency means how open or closed the cervix is, which can affect the progress and outcome of labor and delivery. The cervix is usually closed and firm during pregnancy, but it gradually softens, shortens, and dilates as labor approaches. Checking cervical patency can help to determine if labor has started or if there are any complications such as preterm labor or cervical incompetence.
However, it does not indicate if a spontaneous abortion has occurred or not, as the cervix may remain closed or partially open after a miscarriage. Moreover, checking cervical patency can be invasive and uncomfortable for the woman who has had a spontaneous abortion, and it may increase the risk of infection or bleeding. Therefore, this information should be checked only when indicated by the physician and with caution by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A) Increase oral intake of water between feedings is incorrect because this is not a helpful or recommended measure to help reduce the bilirubin in a newborn who is receiving phototherapy. Bilirubin is a yellow pigment that is produced when red blood cells are broken down. It is normally excreted by the liver into bile and then eliminated by the intestines. However, some newborns have high levels of bilirubin in their blood, which can cause jaundice, a condition that makes the skin and eyes look yellow. Phototherapy is a treatment that uses blue light to help break down the bilirubin and make it easier for the liver to process. Increasing oral intake of water between feedings does not have any effect on the bilirubin level, as water does not contain any nutrients or calories that can stimulate the liver or bowel function. Moreover, giving water to a newborn can cause hyponatremia, which is a low level of sodium in the blood that can lead to seizures, brain damage, or death. Therefore, this measure should be avoided or used with caution for newborns who are receiving phototherapy.
Choice B) Wrap the infant in triple blankets to prevent cold stress during phototherapy is incorrect because this is not a safe or appropriate measure to help reduce the bilirubin in a newborn who is receiving phototherapy. Cold stress is a condition that occurs when a newborn loses too much heat and has difficulty maintaining a normal body temperature. It can cause complications such as hypoglycemia, hypoxia, acidosis, or bleeding. Wrapping the infant in triple blankets may seem like a good way to prevent cold stress, but it can actually cause overheating, dehydration, or hyperthermia, which are equally dangerous for the newborn. Moreover, wrapping the infant in blankets can reduce the effectiveness of phototherapy, as it blocks the exposure of the skin to the blue light. Therefore, this measure should be avoided or used with caution for newborns who are receiving phototherapy.
Choice C) How to prepare the newborn for an exchange transfusion is incorrect because this is not a relevant or necessary measure to help reduce the bilirubin in a newborn who is receiving phototherapy. An exchange transfusion is a procedure that involves replacing some of the newborn's blood with donor blood to lower the bilirubin level and prevent brain damage. It is usually reserved for severe cases of jaundice that do not respond to phototherapy or other treatments. Preparing the newborn for an exchange transfusion involves obtaining informed consent from the parents, placing an umbilical venous catheter, monitoring vital signs and blood tests, and administering medications and fluids. However, these steps are not part of routine care for newborns who are receiving phototherapy, and they do not help to reduce the bilirubin level by themselves. Therefore, this measure should be done only when indicated by the physician and explained by the nurse.
Choice D) Increase the frequency of feedings is correct because this is an effective and recommended measure to help reduce the bilirubin in a newborn who is receiving phototherapy. Feeding provides nutrients and calories that can stimulate the liver and bowel function, which are essential for processing and eliminating bilirubin from the body. Feeding also helps to prevent dehydration, which can worsen jaundice and increase the risk of complications.
Feeding can be done by breast milk or formula, depending on the mother's preference and availability. The frequency of feedings should be increased to at least every 2 to 3 hours or on demand, as long as the newborn shows signs of hunger and satisfaction. Therefore, this measure should be encouraged and supported by the nurse for newborns who are receiving phototherapy.
Correct Answer is D
Explanation
Choice A) Obtain an oxygen saturation: This is not a priority action because it does not address the underlying cause of the respiratory distress, which is meconium aspiration. Meconium aspiration can cause airway obstruction, inflammation, infection, and pulmonary hypertension in the newborn. Oxygen saturation may be low, but it is not a reliable indicator of the severity of the condition.
Choice B) Stimulate the baby to increase respirations: This is not a priority action because it may worsen the respiratory distress by increasing the work of breathing and causing more meconium to be aspirated. Stimulation may also cause stress and hypoxia in the newborn.
Choice C) Prepare to initiate ECMO: This is not a priority action because it is a last resort treatment for severe cases of meconium aspiration syndrome that do not respond to conventional therapies. ECMO stands for extracorporeal membrane oxygenation, which is a form of life support that bypasses the lungs and provides oxygen to the blood.
ECMO has many risks and complications, such as bleeding, infection, and organ damage. It should only be used when other options have failed and with the consent of the parents.
Choice D) Notify the provider at once: This is the correct action because it allows for prompt assessment and intervention by the provider, who can initiate appropriate treatments for meconium aspiration syndrome. These may include suctioning of the airway, administration of antibiotics, surfactant, or inhaled nitric oxide, and mechanical ventilation . Early treatment can improve the outcomes and reduce the complications of meconium aspiration syndrome.
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