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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice B: Administer a bolus infusion of lactated Ringer’s.

Choice A rationale:

Positioning the client in a knee-chest position is not the standard intervention for maternal hypotension following epidural placement. This position is more commonly associated with cord prolapse or to relieve pressure on the vena cava.

Choice B rationale:

Administering a bolus infusion of lactated Ringer’s is the correct action. Hypotension during epidural analgesia is treated with additional intravenous boluses of crystalloid solution. This helps to increase the circulating blood volume and counteract the vasodilation caused by the epidural.

Choice C rationale:

Terbutaline is a medication used to relax the uterus and prevent premature labor, not for treating hypotension.

Choice D rationale:

Applying oxygen via a nonrebreather face mask at 2 L/min is not the primary treatment for maternal hypotension. Oxygen may be used as a supportive measure if there is evidence of fetal distress or maternal hypoxemia, but the first line of treatment for hypotension is fluid administration.

A. Temperature 37.4°C (99.3°F). B. Uterine tenderness. C. WBC Count 9,000/mm. D. Scant lochia.

Correct Answer is B

Explanation

Choice A rationale:

A postpartum temperature of 37.4°C (99.3°F) is within the normal range. Mild temperature elevations can be expected in the immediate postpartum period without indicating infection.

Choice B rationale:

Uterine tenderness is a common finding in endometritis, which is an inflammation or infection of the inner lining of the uterus. The condition can cause pelvic pain and uterine tenderness.

Choice C rationale:

A white blood cell (WBC) count of 9,000/mm³ falls within the normal range for a postpartum client. In endometritis, an elevated WBC count would be expected due to the infection.

Choice D rationale:

Scant lochia (minimal vaginal discharge after childbirth) is a normal finding in the postpartum period and is not associated with endometritis. In endometritis, the lochia may be increased and foul-smelling.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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