A woman is recovering at the gynecologist's office following a first trimester spontaneous abortion. At this time, it is essential for the nurse to check which of the following?
Maternal blood type
Past obstetric history
Maternal varicella titer
Cervical patency
The Correct Answer is A
Choice A) Maternal blood type is correct because this is an essential and relevant information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Spontaneous abortion, also known as miscarriage, is the loss of pregnancy before 20 weeks of gestation. It can be caused by various factors such as chromosomal abnormalities, infections, trauma, or hormonal imbalances. Maternal blood type is the classification of blood based on the presence or absence of antigens and antibodies on the red blood cells and plasma. The most common blood types are A, B, AB, and O, and each can be positive or negative for the Rh factor. Checking maternal blood type can help to identify and prevent Rh incompatibility, which is a condition that occurs when the mother has Rh-negative blood and the fetus has Rh-positive blood. This can cause the mother's immune system to produce antibodies that attack the fetal red blood cells, leading to hemolytic disease of the fetus and newborn (HDFN), which can cause anemia, jaundice, or death. To prevent this, the nurse should administer Rh immunoglobulin (RhoGAM) to the mother within 72 hours after a spontaneous abortion or any event that may cause mixing of maternal and fetal blood. Therefore, this information is vital and appropriate for the nurse to check.
Choice B) Past obstetric history is incorrect because this is not an essential or urgent information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Past obstetric history is the record of previous pregnancies and their outcomes, such as number, duration, complications, or interventions. It can provide useful information for assessing the risk factors and health status of the current pregnancy. However, it does not have any immediate impact or implication for the management of a spontaneous abortion, which is a common and unpredictable event that affects about 10% to 20% of all pregnancies. Therefore, this information can be obtained later or from other sources by the nurse.
Choice C) Maternal varicella titer is incorrect because this is not a relevant or necessary information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Varicella titer is a blood test that measures the level of antibodies against varicella-zoster virus (VZV), which causes chickenpox and shingles. It can indicate whether a person has immunity to VZV or needs vaccination. Checking maternal varicella titer may be important for pregnant women who have not had chickenpox or vaccination before, as VZV infection during pregnancy can cause congenital varicella syndrome (CVS), which can affect the development and function of various organs in the fetus. However, it does not relate to spontaneous abortion, which is not caused by VZV infection or immunity. Therefore, this information is irrelevant and unnecessary for the nurse to check.
Choice D) Cervical patency is incorrect because this is not a reliable or accurate information for the nurse to check for a woman who has had a first trimester spontaneous abortion. Cervical patency means how open or closed the cervix is, which can affect the progress and outcome of labor and delivery. The cervix is usually closed and firm during pregnancy, but it gradually softens, shortens, and dilates as labor approaches. Checking cervical patency can help to determine if labor has started or if there are any complications such as preterm labor or cervical incompetence.
However, it does not indicate if a spontaneous abortion has occurred or not, as the cervix may remain closed or partially open after a miscarriage. Moreover, checking cervical patency can be invasive and uncomfortable for the woman who has had a spontaneous abortion, and it may increase the risk of infection or bleeding. Therefore, this information should be checked only when indicated by the physician and with caution by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A) "Oh, don't worry about that. It's okay." is incorrect because this is not a helpful or informative response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not explain what the black, sticky stuff in the diaper is, why it is there, or how long it will last. It also does not address the father's concern or curiosity, and may make him feel dismissed or ignored. Therefore, this response is inadequate and inappropriate.
Choice B) "That's meconium, which is your baby's first stool. It's normal." is correct because this is a clear and accurate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response explains what the black, sticky stuff in the diaper is, which is meconium. Meconium is a substance that consists of amniotic fluid, mucus, bile, and other waste products that accumulate in the baby's intestines before birth. It is usually passed within the first 24 to 48 hours after birth, and then replaced by transitional or regular stools. Meconium has a dark green or black color and a thick, sticky consistency. It does not have any odor or bacteria. It is normal and harmless for most babies, unless they inhale it during delivery, which can cause breathing problems or infection. Therefore, this response reassures and educates the father about his baby's condition.
Choice C) "That's transitional stool." is incorrect because this is not a true or complete response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not identify what the black, sticky stuff in the diaper is, which is meconium. Transitional stool is a type of stool that appears after meconium and before regular stools. It usually occurs between the second and fifth day after birth, and then changes to yellow or brown stools. Transitional stool has a greenish-brown color and a loose, seedy consistency. It may have some odor or bacteria. It indicates that the baby's digestive system is maturing and adapting to breast milk or formula. Therefore, this response confuses and misleads the father about his baby's condition.
Choice D) "That means your baby is bleeding internally." is incorrect because this is not a valid or appropriate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not describe what the black, sticky stuff in the diaper is, which is meconium. Bleeding internally means that blood vessels are damaged or ruptured inside the body, causing blood loss and shock. This can be caused by various factors such as trauma, infection, clotting disorder, or medication. Bleeding internally can manifest as blood in the stool, urine, vomit, or saliva. However, it does not cause black, sticky stools like meconium. Moreover, this response scares and alarms the father without any evidence or reason. Therefore, this response is false and unethical.
Correct Answer is B
Explanation
Choice A: This is incorrect because Standard Precautions are a set of guidelines that apply to all patients, regardless of their infection status. They include using personal protective equipment, handling sharps and waste properly, and cleaning and disinfecting equipment and surfaces. However, they are not enough to prevent neonatal infection, as some pathogens can still be transmitted by contact or droplet.
Choice B: This is the correct answer because good hand hygiene is the most effective way to prevent the transmission of microorganisms that can cause neonatal infection. The nurse should wash their hands with soap and water or use an alcohol-based hand rub before and after touching the infant, the infant's environment, or any items that come in contact with the infant. The nurse should also educate the parents and visitors on the importance of hand hygiene and how to perform it correctly.
Choice C: This is incorrect because a separate gown technique involves wearing a clean gown for each infant and discarding it after use. This can help prevent cross-contamination between infants, but it does not eliminate the need for hand hygiene. The nurse should still wash their hands before and after wearing a gown, as well as before and after touching the infant or any items that come in contact with the infant.
Choice D: This is incorrect because isolation of infected infants involves placing them in a separate room or area with restricted access and using additional precautions based on the mode of transmission of the infection. This can help prevent the spread of infection to other infants, staff, or visitors, but it does not eliminate the need for hand hygiene. The nurse should still wash their hands before and after entering and leaving the isolation area, as well as before and after touching the infant or any items that come in contact with the infant.
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