A nurse is collecting data from a client who is in her second trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?
Increased abdominal muscle tone
Decreased mobility of pelvic joints
An increase in lordosis
Posterior neck flexion
The Correct Answer is C
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. Excessive uterine enlargement
A hydatidiform mole is a type of gestational trophoblastic disease, where the placenta develops abnormally into a mass of cysts that resemble grape-like clusters. A hydatidiform mole can cause excessive uterine enlargement, as the uterus grows larger than expected for the gestational age. The nurse should measure the fundal height and compare it with the expected value based on the last menstrual period or ultrasound.
The other findings are not associated with a hydatidiform mole and may indicate other conditions.
Whitish vaginal discharge is not a sign of a hydatidiform mole, but it may be normal in pregnancy due to increased cervical mucus production. However, if the discharge is foul-smelling, yellow, green, or bloody, it may indicate an infection or a complication such as preterm labor or placental abruption.
Fetal heart rate irregularities are not a sign of a hydatidiform mole, but they may indicate fetal distress or congenital anomalies. A hydatidiform mole usually does not have a viable fetus, and fetal heart tones are absent or very faint. The nurse should use a Doppler device or a fetal monitor to assess the fetal heart rate and rhythm.
d. Rapidly dropping human chorionic gonadotropin (hCG) levels are not a sign of a hydatidiform mole, but they may indicate a spontaneous abortion or an ectopic pregnancy. A hydatidiform mole usually causes very high hCG levels, as the abnormal placental tissue secretes large amounts of this hormone. The nurse should perform a urine or blood test to measure the hCG levels and monitor them for chan
Correct Answer is B
Explanation
b. Apply an external fetal monitor.
The nurse should apply an external fetal monitor to assess the fetal heart rate and activity, as well as the presence and intensity of contractions. Placenta previa is a condition where the placenta covers part or all of the cervical opening, which can cause painless, bright red bleeding in the third trimester. Placenta previa can compromise fetal oxygenation and perfusion, and can also trigger preterm labor. Therefore, the nurse should monitor the fetal well- being and readiness for delivery.
The other actions are not appropriate and may cause harm to the client or the fetus.
a. The nurse should not perform a rectal exam, as this can cause trauma or infection to the rectum or the placenta, and increase the risk of bleeding or rupture.
c. The nurse should not complete a vaginal exam, as this can dislodge or damage the placenta, and cause severe
hemorrhage or shock.
d. The nurse should not apply ice to the perineal area, as this can cause vasoconstriction and reduce blood flow to the placenta and the fetus, and worsen their condition.
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