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 A

Explanation

Choice A reason:
At 37 weeks, especially in gestational diabetes, fetal lungs may still be immature. Amniocentesis checks lung maturity to ensure the baby can breathe effectively if early delivery is needed due to fetal compromise.

Choice B reason:
Fetal renal function is not typically assessed through amniocentesis at term. Kidney function is monitored via ultrasound, not by analyzing amniotic fluid at 37 weeks.

Choice C reason:
Amniotic fluid glucose levels are not used to manage gestational diabetes. Maternal blood glucose is the standard for monitoring and treatment.

Choice D reason:
Congenital anomalies are usually detected earlier in pregnancy. By 37 weeks, the focus of amniocentesis is on delivery planning, not anomaly detection.

A. Take the patient’s blood pressure. B. Have the patient breathe into her cupped hands. C. Help the patient to turn onto her side. D. Elevate the patient’s legs. E. Elevate the patient’s legs.

Correct Answer is C

Explanation

This is because the patient is experiencing supine hypotension syndrome, which occurs when the weight of the gravid uterus compresses the inferior vena cava and reduces venous return and cardiac output. Turning the patient onto her side will relieve the pressure and improve blood flow.

Choice A is wrong because taking the patient’s blood pressure will not address the cause of her symptoms and may delay appropriate intervention.

Choice B is wrong because breathing into her cupped hands will not improve her circulation and may increase her carbon dioxide levels.

Choice D is wrong because elevating the patient’s legs will not relieve the compression of the inferior vena cava and may worsen her condition.Normal blood pressure for a pregnant woman is 110/70 to 120/80 mmHg.Normal heart rate for a pregnant woman is 60 to 90 beats per minute.Normal respiratory rate for a pregnant woman is 16 to 24 breaths per minute.

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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 client who has gestational diabetes and is scheduled for an amniocentesis at 37 weeks of gestation due to suspected fetal compromise. What is the nurse’s best response to the client’s question as to why the amniocentesis test is being done?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

A patient’s amniotic fluid is meconium-stained. Which action should the nurse plan to take?

The nurse at the antepartal clinic reviews four patients’ charts. Which patient is at increased risk for an ectopic pregnancy?

A patient diagnosed with preeclampsia is admitted to the hospital and prescribed magnesium sulfate therapy. What is the purpose of administering magnesium sulfate to this patient?

A nurse is caring for a newborn who is placed in a neutral thermal environment.What is the desired outcome of this measure?

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A patient who is 33 weeks pregnant has been experiencing Braxton-Hicks contractions.Which information should the nurse include in responding to this patient?

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