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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.

This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.

The duration is measured from the start of one contraction until the end of that same contraction.

Choice A is wrong because it measures the frequency of contractions, not the duration.

The frequency is the time between the start of one contraction and the start of the next one.

Choice B is wrong because it measures only half of the duration of a contraction.

The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.

Choice D is wrong because it measures both the duration and the interval of contractions.

The interval is the time between the end of one contraction and the start of the next one.

Normal ranges for contractions during labor are:

• Duration: 30 to 90 seconds

• Frequency: 2 to 5 minutes apart

• Interval: 30 to 120 seconds

A. Elevate the head of the infant’s crib. B. Apply a water-soluble ointment to the infant’s eyes. C. Dress the infant in a long-sleeved shirt. D. Keep the infant well hydrated.

Correct Answer is D

Explanation

he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin.Hydration helps the infant excrete bilirubin in urine and stool.

Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.

Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation.The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.

Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy.The infant should be undressed except for a diaper and eye protection during phototherapy.

Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement.Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is in labor and is placed on a monitor.How should the nurse determine the duration of contractions?

Correct Answer is C

Explanation

A newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy. Which measure is an important part of this newborn’s care plan?

Correct Answer is D

Explanation

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