A client at 8-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the practical nurse (PN) take?
Check serum human chorionic gonadotropin.
Verify the date of the last menstrual cycle.
Repeat a urine pregnancy test.
Inquire about the last occurrence of intercourse.
The Correct Answer is A
The first action the PN should take is to check the client's serum human chorionic gonadotropin (hCG) level. This hormone is produced by the placenta and can provide important information about the viability of the pregnancy.
Option B, verifying the date of the last menstrual cycle, can provide useful information about the gestational age of the pregnancy but is not the first priority.
Option C, repeating a urine pregnancy test, can confirm the presence of a pregnancy but does not provide information about its viability.
Option D, inquiring about the last occurrence of intercourse, is not relevant to addressing the client's immediate concern of vaginal bleeding.
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Related Questions
Correct Answer is D
Explanation
An increasing trend in maternal heart rate is a sign of fetal distress, which can be a serious complication of PROM. One of the primary interventions for fetal distress is to increase oxygen delivery to the fetus. The practical nurse should initiate oxygen via face mask at 8 to 10 L/min to improve fetal oxygenation.
Contact precautions may be necessary for certain conditions, but they are not indicated for an increasing maternal heart rate.
Inserting a urinary catheter may be appropriate for monitoring output, but it is not the first priority in this situation.
Encouraging the client to push is not appropriate because the client is not in active labor and pushing can cause further complications.
Correct Answer is A
Explanation
The practical nurse (PN) should obtain a serum glucose level to assess the client's blood sugar level, which can help to determine if the client is experiencing hyperglycemia or diabetic ketoacidosis (DKA). Anorexia, drowsiness, and polydipsia, along with the reported frequent urination and bedwetting, are symptoms of hyperglycemia or DKA.
Offering age-appropriate toys (B) or suggesting diapers for bedtime use (C) are not appropriate actions for the PN to take in this situation.
Bringing orange juice and crackers (D) may help to increase the client's blood sugar level in the short term, but it does not address the underlying issue and may exacerbate the client's symptoms if she is experiencing hyperglycemia or DKA.
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