A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?
Severe nausea and vomiting.
Pelvic pain.
Uterine enlargement greater than expected for gestational age.
Copious vaginal bleeding.
The Correct Answer is B
Choice A rationale:
Severe nausea and vomiting are not indicative of an ectopic pregnancy. While nausea and vomiting are common symptoms in early pregnancy, they are not specific to ectopic pregnancies. These symptoms are more likely associated with typical pregnancy changes.
Choice B rationale:
Pelvic pain is a crucial finding that the nurse should expect in a possible ectopic pregnancy. As the pregnancy implants outside of the uterus, usually in the fallopian tube, it can cause sharp and severe pain in the pelvic region. This pain may be unilateral and can be accompanied by shoulder pain due to blood or fluid irritating the diaphragm.
Choice C rationale:
Uterine enlargement greater than expected for gestational age is not likely in an ectopic pregnancy. In fact, uterine enlargement may not be noticeable at all in an ectopic pregnancy since the embryo is not developing in the uterus.
Choice D rationale:
Copious vaginal bleeding is more commonly associated with miscarriages or other complications in intrauterine pregnancies. In an ectopic pregnancy, vaginal bleeding may occur, but it is typically lighter and often described as spotting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This statement is incorrect because Rho(D) immune globulin does not destroy Rh antibodies in a newborn who is Rh-positive. Instead, it acts to prevent the development of Rh antibodies in the mother.
Choice B rationale:
This statement is also incorrect. Rho(D) immune globulin does not destroy Rh antibodies in a woman who is Rh-negative. It is given to Rh-negative women to prevent them from forming Rh antibodies in response to Rh-positive fetal blood during pregnancy.
Choice C rationale:
This is the correct choice. Rho(D) immune globulin is given to Rh-negative women to prevent the formation of Rh antibodies. If an Rh-negative woman is exposed to Rh-positive blood (usually during childbirth), her immune system may recognize the Rh antigen as foreign and start producing Rh antibodies. These antibodies could potentially cross the placenta during a subsequent pregnancy and attack the red blood cells of an Rh-positive fetus, causing hemolytic disease in the newborn. Rho(D) immune globulin helps prevent this sensitization process.
Choice D rationale:
This statement is incorrect. Rho(D) immune globulin does not prevent the formation of Rh antibodies in a newborn who is Rh-positive. Its main purpose is to protect Rh-negative women from forming antibodies that could harm future Rh-positive pregnancies.
Correct Answer is ["A","B","F"]
Explanation
Choice A rationale:
The nurse should report visual disturbances to the provider. Visual disturbances in a pregnant client could indicate potential complications such as preeclampsia or eclampsia. These conditions are characterized by high blood pressure and can be harmful to both the mother and the fetus. Reporting visual disturbances promptly allows the provider to assess the situation and take appropriate actions to ensure the safety of the client and the baby.
Choice B rationale:
The nurse should also report blood pressure changes to the provider. The client's blood pressure has increased significantly from 179/99 mm Hg to 170/101 mm Hg over a short period. High blood pressure during pregnancy can be indicative of preeclampsia, a serious condition that requires close monitoring and management to prevent complications. Reporting the blood pressure changes promptly allows the provider to evaluate the situation and intervene as needed to safeguard the client's well-being.
Choice F rationale:
The nurse should report the fetal heart rate to the provider. Monitoring the fetal heart rate is crucial in prenatal care as it helps assess the well-being of the baby. Any abnormality in the fetal heart rate could indicate fetal distress or other complications. Promptly reporting any concerning changes in the fetal heart rate enables the provider to take appropriate measures to ensure the health and safety of the baby. The other choices (C, D, and E) are not the most critical findings in this scenario. While respiratory rate (C), deep tendon reflexes (D), and weight (E) are important aspects to monitor during pregnancy, they do not raise immediate concerns for potential complications like visual disturbances, blood pressure changes, and fetal heart rate abnormalities mentioned above. Nonetheless, they should still be documented and monitored regularly as part of routine prenatal care.
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