A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy.
Which of the following actions should the nurse take?
Inform the client to expect to have dark-colored stools.
Wear two pairs of gloves when handling the medication.
Administer the medication subcutaneously.
Instruct the client to use a condom during intercourse for the next 7 days.
The Correct Answer is B
Choice A rationale
Informing the client to expect dark-colored stools is inaccurate for methotrexate administration. Dark stools typically indicate gastrointestinal bleeding, not a side effect of methotrexate.
Choice B rationale
Wearing two pairs of gloves is necessary when handling methotrexate as it is a cytotoxic drug. This protects healthcare workers from accidental exposure to the medication, which can be harmful.
Choice C rationale
Methotrexate is typically administered intramuscularly or orally, not subcutaneously. Administering it subcutaneously is incorrect and would not be effective for treating an ectopic pregnancy.
Choice D rationale
While it is essential to counsel the client on safe intercourse practices, instructing to use a condom for only 7 days post-administration is not specific or relevant to the methotrexate therapy for ectopic pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The fetal heartbeat is typically detectable by Doppler around 10-12 weeks, not as early as 6 weeks.
Choice B rationale
Monthly prenatal visits up to 28 weeks are standard practice for monitoring pregnancy.
Choice C rationale
A complete blood count is not performed at every prenatal visit but at specific intervals.
Choice D rationale
The blood test for neural tube defects, such as AFP, is usually done around 16-18 weeks, not 32 weeks.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
The nurse should identify that the client is at the greatest risk for preterm birth due to:
Response 1: B) being higher than normal (fetal fibronectin: 0.09 mcg/mL is higher than the normal level of ≤ 0.05 mcg/mL).
Response 2: B) Nitrazine and ferning tests negative
Here's the
- Fetal Fibronectin: Fetal fibronectin is a protein found between the amniotic sac and the uterine lining. Levels greater than 0.05 mcg/mL (like 0.09 mcg/mL) indicate an increased risk of preterm labor.
- Nitrazine and Ferning Tests: Both tests being negative indicates that there is no rupture of membranes. Even though these tests are negative, the elevated fetal fibronectin level still indicates a risk for preterm birth.
So the completed sentence would be: The nurse should identify that the client is at the greatest risk for preterm birth due to fetal fibronectin being higher than normal and Nitrazine and ferning tests negative.
This combination of findings suggests that preterm labor may be imminent despite the lack of membrane rupture. The elevated fetal fibronectin is a strong indicator of risk.
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