A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment.
Which of the following laboratory tests should the nurse plan to conduct?

Rationales for Each Condition

Molar Pregnancy

1. Abdominal Pain: In a molar pregnancy, the uterus enlarges disproportionately due to abnormal trophoblastic growth. This excessive expansion can cause discomfort or mild cramping.
2. Blood Pressure: Molar pregnancies can be associated with gestational trophoblastic disease, which may lead to preeclampsia-like symptoms. However, this client’s blood pressure is currently within normal limits (120/78 mm Hg), so severe hypertension has not yet developed.
3. Ultrasound Findings: The presence of grape-like vesicles within the uterus and the absence of a fetal heartbeat are hallmark findings of a molar pregnancy, indicating abnormal placental tissue proliferation.
4. Perineal Pad Findings: The passage of small clear vesicles is a characteristic feature of a molar pregnancy, distinguishing it from other causes of vaginal bleeding in pregnancy.

Ectopic Pregnancy

1. Abdominal Pain: Ectopic pregnancies often cause sharp lower abdominal pain due to tubal rupture or irritation. However, in this case, the client’s pain is mild and less suggestive of tubal rupture.
2. Blood Pressure: If an ectopic pregnancy ruptures, hypotension due to internal bleeding would be expected. Since the client’s blood pressure is normal, this finding does not support an ectopic pregnancy.
3. Ultrasound Findings: The absence of a fetal heartbeat and vesicular structures inside the uterus make ectopic pregnancy unlikely, as ectopic pregnancies typically occur in the fallopian tube.
4. Perineal Pad Findings: Ectopic pregnancies rarely cause the passage of vesicular tissue, further suggesting that this is not an ectopic pregnancy.

Rationale for Correct Condition

Subinvolution refers to delayed uterine involution, often due to retained placental fragments or infection. The boggy uterus, excessive lochia, and passage of clots are hallmark signs. The history of postpartum hemorrhage increases risk, and fundal tenderness suggests uterine atony rather than infection or hematoma formation.

Rationale for Correct Actions

Oxytocin enhances uterine contractions to reduce bleeding and facilitate involution by increasing myometrial tone. Methylergonovine is a potent uterotonic that further supports contraction, decreasing hemorrhage risk, but must be used cautiously in hypertensive patients.

Rationale for Correct Parameters

Saturated perineal pads track blood loss severity, guiding interventions for ongoing hemorrhage. Excessive bleeding may require further medical management. Hemoglobin and hematocrit assess for anemia due to blood loss, guiding transfusion decisions if needed.

Rationale for Incorrect Conditions

Postpartum preeclampsia presents with hypertension and proteinuria, not uterine atony. Perineal hematoma manifests as localized swelling with severe perineal pain, which is absent here. Thrombophlebitis involves unilateral extremity swelling and pain, not fundal tenderness or abnormal lochia.

Rationale for Incorrect Actions

Ice packs to the perineum manage hematomas, not uterine atony. Anticoagulants are used for thromboembolic prevention, not postpartum bleeding. Quiet environment is relevant for preeclampsia, not uterine subinvolution.

Rationale for Incorrect Parameters

Seizures are relevant to preeclampsia, not uterine subinvolution. Calf circumference is monitored for thrombophlebitis, which is absent here. Rectal pain is not an expected indicator of uterine involution status.