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 D

Explanation

The correct answer is choice D. Insufficient relaxation of the uterus between contractions.This is also known astachysystoleorhyperstimulation, which can cause fetal distress and uterine rupture.Oxytocin is a hormone that stimulates uterine contractions, but it can also cause them to be too strong or too frequent if given in high doses or for too long.

Choice A is wrong because oxytocin does not decrease body temperature.

Choice B is wrong because oxytocin does not cause maternal cardiac arrhythmias.

Choice C is wrong because oxytocin does not cause urinary retention.

A. Trying to reassure herself concerning the present situation. B. Coping as expected in this situation. C. Anxious to see the new baby. D. Able to use previously learned knowledge in a new situation.

Correct Answer is A

Explanation

The correct answer is choice A. The client is trying to reassure herself concerning the present situation.This is a common coping strategy for women who face the risk of preterm labor and delivery.The client may be experiencing fear, anxiety, or denial about the possible outcomes of her pregnancy.

Choice B is wrong because coping as expected in this situation implies that there is a normal or standard way of coping with preterm labor, which is not true.Different women may cope differently depending on their personal, social, and emotional factors.

Choice C is wrong because anxious to see the new baby does not reflect the client’s statement.

The client is not expressing excitement or eagerness about the birth, but rather a rationalization that everything will be okay despite the risks.

Choice D is wrong because able to use previously learned knowledge in a new situation does not apply to the client’s statement.

The client is not using her sister’s experience as a source of information or guidance, but rather as a way of minimizing or dismissing her own situation.

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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 receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

Correct Answer is D

Explanation

A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried. My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.

Correct Answer is A

Explanation

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