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 B
Explanation
The correct answer is choice B. “You are doing a great job.
It’s very difficult to support someone during this part of labor.” This response acknowledges the husband’s feelings and efforts, and provides reassurance and encouragement.
It also reflects the reality that active labor can be very intense and painful for the woman, and she may not want to be touched or talked to.
Choice A is wrong because it suggests that the husband is not needed or wanted, and may make him feel rejected or useless.
Choice C is wrong because it implies that the husband is not a good support person, and may hurt his self-esteem or damage his relationship with his wife.
Choice D is wrong because it focuses on the physical aspect of labor, rather than the emotional one.
It also assumes that the woman wants medication, which may not be the case.
Correct Answer is A
No explanation
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