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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Measure vital signs.

Obtain human chorionic gonadotropin levels.

Collect urine sample for urinalysis.

Recommend bed rest.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.

Choice B rationale

Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.

Choice C rationale

Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.

Choice D rationale

Recommending bed rest is not the most appropriate action based on the given symptoms.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Reviewing the pattern of the fetal heart rate is important but not the immediate first step when a client in active labor needs to use the restroom. The nurse should first assess the progress of labor.

Choice B rationale: Checking the client's bladder is necessary, especially if the bladder is full, as it can affect labor progress. However, the priority is to assess the cervix first to ensure the client is not in an advanced stage of labor before addressing bladder concerns.

Choice C rationale: Determining the dilation of the cervix is crucial. The need to use the restroom may indicate increased pressure from the presenting part of the fetus, suggesting rapid labor progression. This assessment will help determine if it is safe for the client to ambulate to the restroom or if other immediate actions are needed.

Choice D rationale: Testing the pH of the vaginal fluid can be part of assessing for the presence of amniotic fluid, but it is not the first step when a client in active labor expresses the need to use the restroom. Cervical assessment takes priority in this situation.

A. Contact spiritual support services. B. Provide information about an autopsy. C. Discuss neonatal resuscitation options. D. Get in touch with the organ donation organization.

Correct Answer is A

Explanation

Choice A rationale

In a situation where a client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery, the nurse’s initial action should be to contact spiritual support services. This can provide much-needed emotional and spiritual support to the client during this difficult time.

Choice B rationale

While providing information about an autopsy might be necessary at some point, it should not be the initial action. The first response should be focused on providing emotional support.

Choice C rationale

Discussing neonatal resuscitation options might not be appropriate in this scenario, especially if it’s not expected that the fetus will survive. The initial focus should be on providing emotional support.

Choice D rationale

Contacting the organ donation organization is not the initial action to take in this situation. The first response should be providing emotional and spiritual support to the client.

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who has been admitted in active labor. The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom. What should be the nurse’s first course of action?

Correct Answer is C

Explanation

A client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery. What should be the nurse’s initial action?

Correct Answer is A

Explanation

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?