A nurse is assisting with the care of a client who is pregnant.
Complete the diagram by dragging from the choices below to specify what condition the client is meet likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to determine the client's progress.
The Correct Answer is []
- Prepare the client for an emergency cesarean birth: Emergency cesarean delivery is indicated in cases of fetal distress or placenta previa with severe bleeding at term. In a hydatidiform mole, there is no viable fetus, and the priority is evacuation of the molar tissue rather than delivery by cesarean section.
- Prepare the client for suction curettage: Suction curettage is the treatment of choice for a hydatidiform mole. It allows for the complete evacuation of abnormal trophoblastic tissue, preventing complications such as severe hemorrhage and progression to malignant gestational trophoblastic disease.
- Anticipate a prescription for methotrexate: Methotrexate is primarily used to treat ectopic pregnancies or persistent gestational trophoblastic disease after a molar pregnancy, not for initial management. Immediate evacuation of the mole by suction curettage is the first-line intervention for this client.
- Remind the client that weekly blood tests are needed to measure pregnancy hormone: Following a molar pregnancy, weekly beta-hCG tests are critical to monitor for residual trophoblastic tissue or the development of choriocarcinoma. A declining beta-hCG confirms the resolution of disease, while a plateau or rise indicates persistent disease.
- Administer terbutaline: Terbutaline is a tocolytic medication used to relax the uterus in cases of preterm labor. In the case of a hydatidiform mole, uterine evacuation is necessary rather than uterine relaxation, making terbutaline inappropriate for this situation.
- Vaginal bleeding: Clients with a hydatidiform mole are at risk for significant vaginal bleeding due to the abnormal growth of trophoblastic tissue. Monitoring the amount and type of vaginal bleeding helps detect hemorrhage or retained molar tissue requiring urgent intervention.
- Blood pressure: Elevated blood pressure is a potential complication of hydatidiform mole, similar to preeclampsia, and can occur even in the first or second trimester. Regular monitoring of blood pressure is essential to detect worsening hypertensive symptoms early.
- Uterus for hypertonicity: Hypertonicity of the uterus is typically monitored in cases of labor or uterine rupture concerns. In a hydatidiform mole, the uterus is distended by abnormal tissue but hypertonicity is not a primary concern needing monitoring in this condition.
- Unilateral pelvic pain: Unilateral pelvic pain is more characteristic of ectopic pregnancy rather than a molar pregnancy. In hydatidiform mole, generalized uterine enlargement and discomfort are more typical, so unilateral pelvic pain is not a focus for this client.
- Cervical dilation per provider: Cervical dilation is not the main indicator of progress or concern with a molar pregnancy. The focus is on removing molar tissue and monitoring beta-hCG levels, not on the progress of cervical changes like in labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. WBC count 12,000/mm³: A mild elevation in white blood cell count is expected within the first few days postpartum as part of the normal inflammatory response due to the stress of labor and delivery.. A count of 12,000/mm³ is not alarming and does not necessarily indicate infection or a complication.
B. Temperature 37.8°C (100°F): A low-grade temperature elevation within the first 24 hours postpartum is common due to hormonal shifts, dehydration, or exertion from labor. This finding would not immediately require provider notification unless it persists or rises higher.
C. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within normal adult limits and does not suggest respiratory distress or any postpartum complication, so no intervention is required for this finding.
D. Hgb 8 g/dL: A hemoglobin level of 8 g/dL is significantly low and can indicate postpartum hemorrhage or significant blood loss. This degree of anemia should be reported promptly to the provider to assess the need for interventions such as blood transfusion or iron supplementation.
Correct Answer is C
Explanation
A. Place the client on bedrest: While limiting the client’s activity is important to reduce oxygen demand, it is not the first priority. Immediate actions should focus on improving oxygenation and reducing respiratory distress.
B. Obtain the client's ABG levels: Although obtaining arterial blood gases provides valuable information about oxygenation and acid-base balance, it does not address the immediate need to relieve the client's breathing difficulty and hypoxia.
C. Elevate the head of the client's bed: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the first action to reduce dyspnea and ease the client’s breathing. It is a simple, quick intervention that can stabilize the client while further assessments are conducted.
D. Prepare the client for a ventilation-perfusion scan: A V/Q scan may be indicated to diagnose conditions like pulmonary embolism, but it is a diagnostic step that follows stabilization. Immediate efforts must first focus on ensuring adequate oxygenation and respiratory support.
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