A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?
Scant, bright red spotting.
Elevated hCG.
Cervical dilation.
Slight abdominal cramps.
The Correct Answer is C
Choice A rationale:
Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.
Choice B rationale:
Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.
Choice C rationale:
Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.
Choice D rationale:
Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Determining gestational age in the first trimester is a common and important use of ultrasound. It helps confirm the estimated due date and monitor the fetus's growth and development.
Choice B rationale:
Performing a biophysical profile in the first trimester is not a common use of ultrasound. Biophysical profiles are usually performed in the second or third trimester to assess fetal well-being.
Choice C rationale:
Observing placental maturity in the first trimester is not a standard use of ultrasound. Placental maturity is typically assessed later in pregnancy, especially in the third trimester.
Choice D rationale:
Detecting intrauterine growth restriction in the first trimester is not a primary use of ultrasound. Intrauterine growth restriction is more commonly assessed in the later stages of pregnancy when fetal growth is a concern.
Correct Answer is C
Explanation
The correct answer is c. Cleanse the newborn immediately after delivery. This is because cleansing the newborn can reduce the risk of HIV transmission through exposure to maternal blood or fluids. The other options are not appropriate for the following reasons:
a. Administer IV antibiotics to the newborn. This is not necessary unless the newborn has signs of infection or sepsis. Antibiotics do not prevent or treat HIV infection.
b. Encourage the mother to breastfeed her newborn. This is contraindicated for mothers with HIV, as breastfeeding can transmit the virus to the infant. Mothers with HIV should avoid breastfeeding and use formula or donor milk instead.
d. Initiate contact precautions for the newborn. This is not required for newborns exposed to HIV, as HIV is not transmitted by casual contact. Standard precautions are sufficient to prevent the spread of HIV and other bloodborne pathogens.
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