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
Answer and explanation..
The correct answer is choice C. Jitteriness.Jitteriness is a sign of low blood sugar (hypoglycemia) which is common in infants of diabetic mothers (IDM) because they have high levels of insulin in their blood that lower their glucose levels after birth.Hypoglycemia can also cause other symptoms such as seizures, lethargy, poor feeding, sweating, trembling, and pale complexion.
Choice A is wrong because abdominal distention is not a typical symptom of IDM.
It can be caused by other conditions such as intestinal obstruction or infection.
Choice B is wrong because high-pitched cry is not a specific symptom of IDM.
It can be caused by many factors such as pain, hunger, or neurological problems.
Choice D is wrong because excessive drooling is not a common symptom of IDM.
It can be a sign of oral problems such as teething or infection.
Normal ranges for blood glucose in newborns are 40 to 150 mg/dL (2.2 to 8.3 mmol/L).
IDM should be monitored closely for hypoglycemia and treated promptly with glucose if needed.
Correct Answer is A
Explanation
he correct answer is choice A. “Instead of having eggs, I am eating yogurt for breakfast.” This statement shows a need for further instruction because eggs are a good source of protein and yogurt is not.
Yogurt is a dairy product that contains mostly carbohydrates and some fat.
Eggs are an animal product that contains mostly protein and some fat.
Protein is important for building and repairing tissues in the body.
Choice B is correct because adding powdered milk to skim milk increases the protein content of the drink.
Powdered milk is a dairy product that contains protein, carbohydrates and fat.
Skim milk is a dairy product that contains protein and carbohydrates but no fat.
Choice C is correct because peanut butter is a good source of protein and healthy fats.
Peanut butter is a plant product that contains protein, fat and some carbohydrates.
Crackers are a grain product that contains mostly carbohydrates and some protein.
Choice D is correct because cream of tomato soup is a good source of protein and calories.
Cream of tomato soup is a processed food that contains tomatoes, cream, flour and seasonings.
Tomatoes are a vegetable that contains mostly water and some carbohydrates.
Cream is a dairy product that contains mostly fat and some protein.
Flour is a grain product that contains mostly carbohydrates and some protein.
Seasonings are herbs and spices that contain mostly flavor and some nutrients.
The normal range of protein intake for adults is 0.8 to 1 gram per kilogram of body weight per day.
This means that an adult who weighs 70 kilograms should consume about 56 to 70 grams of protein per day.
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