A client at 6-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the nurse take?
Check serum human chorionic gonadotropin.
Verify the date of the last menstrual cycle.
Inquire about the last occurrence of intercourse.
Repeat a urine pregnancy test.
The Correct Answer is A
Choice A rationale
Checking serum human chorionic gonadotropin (hCG) levels is the appropriate action. hCG levels can help determine the viability of the pregnancy. Decreasing hCG levels may indicate a non-viable pregnancy, while increasing levels suggest a viable pregnancy.
Choice B rationale
Verifying the date of the last menstrual cycle is important but not the priority action in this scenario. While it can provide information on gestational age, it does not directly address the concern of vaginal bleeding.
Choice C rationale
Inquiring about the last occurrence of intercourse is not directly related to assessing the cause of vaginal bleeding. It may provide additional history but does not address the immediate concern.
Choice D rationale
Repeating a urine pregnancy test is not necessary in this context. The client is already known to be pregnant, and a urine test will not provide additional information regarding the cause of the bleeding.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
An audible murmur in a neonate with a ventricular septal defect (VSD) is a common finding and does not typically require immediate intervention. While it indicates a cardiac anomaly, it is not an emergency.
Choice B rationale
Fatigue after feedings in a neonate with patent ductus arteriosus (PDA) is a sign of increased cardiac workload, but it does not indicate an immediate life-threatening situation. It requires monitoring but not urgent intervention.
Choice C rationale
Elevated blood pressure in the upper extremity in a neonate with coarctation of the aorta is a concerning finding that indicates a narrowing of the aorta. While it requires prompt evaluation and management, it may not be as immediately critical as a hypercyanotic spell.
Choice D rationale
A neonate with Tetralogy of Fallot (TOF) experiencing hypercyanotic (Tet) spells and crying indicates a severe decrease in oxygenation and is an emergency. This condition requires immediate intervention to improve oxygenation and prevent complications such as brain damage or death. .
Correct Answer is A
Explanation
Choice A rationale
Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.
Choice B rationale
Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.
Choice C rationale
The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.
Choice D rationale
Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .
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