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The nurse is caring for the client who is Rh negative at 13 weeks’ gestation. The client is having cramping and has moderate vaginal bleeding. Which HCP order should the nurse question?
- A. Administer Rho(D) immune globulin (RhoGAM).
- B. Obtain a beta human chorionic gonadotropin level (BHCG).
- C. Schedule for an immediate ultrasound.
- D. Place on continuous external fetal monitoring.
Correct Answer: B
Rationale: Obtaining the BHCG level is not indicated at 13 weeks’ gestation. BHCG levels are followed in early pregnancy before a fetal heartbeat can be confirmed. RhoGAM is indicated for any pregnant client with bleeding who is Rh negative. An ultrasound can identify the cause of bleeding and confirm fetal viability. Continuous external fetal monitoring can be used to confirm a fetal heartbeat, fetal viability, and fetal risk.
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The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client’s fetus has been lost?
- A. Falling beta human chorionic gonadotropin (BHCG) measurement
- B. Low progesterone measurement
- C. Ultrasound showing a lack of fetal cardiac activity
- D. Ultrasound determining crown-rump length
Correct Answer: C
Rationale: Ultrasound is used to determine if the fetus has died. The lack of fetal heart activity in a pregnancy over 6 weeks determines a fetal loss. Falling BHCG levels do not conclusively diagnose fetal demise. Low progesterone levels do not conclusively diagnose fetal demise. Crown-rump length determines only the fetal gestational age.
Which sign of labor should the nurse teach the client to report immediately?
- A. Mild, irregular contractions
- B. Increased fetal movement
- C. Rupture of membranes
- D. Occasional backache
Correct Answer: C
Rationale: Rupture of membranes (water breaking) requires immediate reporting, as it may indicate the onset of labor or risk of infection.
On the basis of the health history data, how should the nurse record the client's pregnancy status on the prenatal records?
- A. Multipara
- B. Primipara
- C. Primigravida
- D. Multigravida
Correct Answer: C
Rationale: A primigravida is a woman pregnant for the first time, which matches the client's status of being possibly 2 months pregnant with no prior pregnancies.
Which statement made by a participant regarding remedies of heartburn and nausea indicates that teaching has been effective?
- A. I should eat frequent, small meals.
- B. I should take an antacid after eating.
- C. I should eat my largest meal in the evening.
- D. I should drink extra water with my meals.
Correct Answer: A
Rationale: Frequent, small meals reduce stomach acid and nausea, unlike large meals or extra water, which may worsen symptoms.
The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse’s interventions in the sequence that they should occur.
- A. Administer oxygen via facemask
- B. Have the HCP paged if the prolonged decelerations have not resolved.
- C. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the heart rate remains low.
- D. Increase the rate of the intravenous (IV) fluids
- E. Assist the client into a different position
- F. Prepare for a vaginal examination and fetal scalp stimulation
Correct Answer: E,A,D,B,F,C
Rationale: Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to relieve the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapse and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low.