A 23-year-old primigravida who appears to be in her third trimester of pregnancy comes to the labor and delivery unit reporting acute abdominal pain. She has had no prenatal care. Which assessment should the nurse do first?
Obtain a full history.
Examine the cervix for dilation
Examine the cervix for dilation.
Palpate for uterine contraction frequency
The Correct Answer is C
This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor. Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.
Choice A: Obtain a full history is wrong because it is not the most urgent action.
A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.
Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases. A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.
Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.
Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor. Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.
Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The patient should palpate her breasts using the padded sections of her fingers.This is the recommended technique for breast self-examination, as it allows the patient to feel any changes or lumps in the breast tissue.
Choice A is wrong because the patient should perform breast self-examination at the same time each month, preferably a few days after the menstrual period ends when the breasts are less likely to be swollen or tender.
Choice B is wrong because the patient should not assume that any lumps that are present in both breasts are normal.Some breast cancers can affect both breasts, and any new or unusual lumps should be reported to a doctor.
Choice D is wrong because the patient should look at her breasts while standing in front of the mirror with her arms at her sides, raised overhead, and pressed firmly on her hips.She should also look for any changes in the shape, size, color, or texture of her breasts and nipples.
Correct Answer is C
Explanation
The correct answer is choice C. Ask what the patient ate and drank within the last day or two.This is because the nurse needs to assess the patient’s current nutritional status and eating habits before providing any education or advice.The nurse can then tailor the counseling to the patient’s specific needs and preferences.
Choice A is wrong because it is not the first action that the nurse should take.While it is important to explain the importance of adequate nutrition for the patient’s own growth and development, this should be done after assessing the patient’s current situation.
Choice B is wrong because it is not the first action that the nurse should take.While it is important to explain the relationship between the patient’s eating habits and fetal development, this should be done after assessing the patient’s current situation.
Choice D is wrong because it is not the first action that the nurse should take.While it is important to discuss with the patient the basic nutritional requirements of pregnancy, this should be done after assessing the patient’s current situation.
The normal ranges for nutritional intake during pregnancy vary depending on the age, weight, activity level, and health status of the patient.
However, some general guidelines are:
• Increase calorie intake by about 300 calories per day
• Increase protein intake by about 25 grams per day
• Increase calcium intake by about 1000 milligrams per day
• Increase iron intake by about 27 milligrams per day
• Increase folic acid intake by about 600 micrograms per day
• Increase fluid intake by about 8 to 10 cups per day
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