A nurse in an acute mental health facility is assessing a client who is experiencing auditory command hallucinations. Which of the following questions should the nurse ask first?

Rationale for correct choices

• Spontaneous abortion: The client is presenting at 10 weeks gestation with moderate, bright red vaginal bleeding and a history of risk factors including type 1 diabetes mellitus and recurrent infections. The open cervix on examination indicates that the pregnancy may not be viable and suggests impending or ongoing miscarriage.

• Cervical dilation: Cervical dilation is a key clinical sign of spontaneous abortion, as it indicates that the body is preparing to expel the pregnancy. The presence of an open cervix in conjunction with vaginal bleeding and cramping directly supports the risk for miscarriage. Monitoring cervical changes helps the healthcare team assess the progression and urgency of intervention.

Rationale for incorrect choices

• Molar pregnancy: Molar pregnancy typically presents with markedly elevated hCG levels, larger-than-expected uterine size, and absence of a viable embryo. Although the client has an elevated hCG, the level is not excessively high, and there is no indication of vesicular tissue or characteristic ultrasound findings, making molar pregnancy unlikely.

• Ectopic pregnancy: Ectopic pregnancy generally presents with unilateral abdominal pain, shoulder pain, and sometimes hypotension or signs of internal bleeding. The client’s bleeding is bright red, moderate, and accompanied by cervical dilation, which is not typical for an ectopic pregnancy. No abdominal mass or unilateral tenderness is reported, reducing the likelihood of this diagnosis.

• Lower abdominal cramping: While cramping is a symptom associated with miscarriage, it alone is not sufficient evidence to determine the risk for spontaneous abortion. Cervical dilation is a more definitive clinical sign indicating that the miscarriage may be occurring or imminent.

• hCG levels: The client’s hCG level of 30,000 IU/L is within the expected range for 10 weeks gestation and does not specifically indicate miscarriage. Unlike cervical dilation, hCG levels alone cannot confirm the risk for spontaneous abortion.

Rationale:

A. Remove the cap and place it sterile-side up on a clean surface: Placing the cap with the sterile side up can contaminate the inside of the cap and potentially the solution. The cap should be placed sterile-side down or on a clean, nonsterile surface to prevent contamination of the sterile solution.

B. Hold the bottle in the center of the sterile field when pouring the solution: Placing the bottle over the sterile field risks contaminating it if any part of the bottle or solution touches the sterile area. The bottle should be held outside the sterile field and poured carefully to maintain sterility.

C. Place sterile gauze over areas of spilled solution within the sterile field: Once a sterile field is contaminated by spilled solution, it cannot be safely salvaged by placing sterile gauze over it. Any contamination requires replacement of the affected items to maintain aseptic technique.

D. Hold the irrigation solution bottle with the label facing away from the palm of the hand: This technique prevents the solution from contacting the label, which could obscure important information or lead to accidental contamination. Proper handling preserves sterility while ensuring the label remains legible for verification.