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 D
Explanation
The correct answer is choice D. If the client feels like she has butterflies in her stomach, it means her baby is moving.
This is a normal and expected change during pregnancy, especially in the second and third trimesters.The baby’s movements can be felt as flutters, kicks, or rolls.
Choice A is wrong because spotting of blood on the underwear is not a normal change during pregnancy.
It can indicate a problem such as placenta previa, placental abruption, or miscarriage.Any bleeding during pregnancy should be reported to the health care provider.
Choice B is wrong because clear fluid leaking from the vagina is not a normal change during pregnancy.
It can indicate that the membranes have ruptured and amniotic fluid is escaping.
This can lead to infection and preterm labor if not treated promptly.Any fluid leakage during pregnancy should be reported to the health care provider.
Choice C is wrong because dark patches on the face are not a sign of high blood pressure during pregnancy.
They are called melasma or chloasma and are caused by increased pigmentation due to hormonal changes.They usually fade after delivery and are not harmful.High blood pressure during pregnancy can cause symptoms such as headache, blurred vision, swelling, and protein in the urine.
Correct Answer is B
Explanation
he correct answer is choice B. Sufficient perfusion and circulation of the fetus.This is because the fetal heart rate is within the normal range of 110 to 160 beats per minute, and there is moderate beat-to-beat variability, which indicates a healthy nervous system.
Choice A is wrong because insufficient perfusion of the placenta would cause fetal distress and abnormal fetal heart rate patterns, such as late decelerations or minimal variability.
Choice C is wrong because maternal hypoxia would not directly affect the fetal heart rate, unless it leads to placental insufficiency or uterine hyperstimulation.
Choice D is wrong because fetal hypoxia would cause signs of fetal distress, such as tachycardia, bradycardia, or absent variability.
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