Correct answer-A. Rationales: Ectopic pregnancies that are leaking or have ruptured result in referred pain to the shoulder from blood irritating the diaphragm. Sharp upper abdominal pain is too high for pain caused by an ectopic pregnancy. Flank pain may be associated with kidney infection or kidney stones. Colicky, diffuse abdominal pain is commonly associated with intestinal disorders.

Nursing process step: Assessment

Correct answer-C. Rationales: Placenta previa is associated with painless vaginal bleeding that occurs when the placenta, or a portion of the placenta, covers the cervical os. In abruptio placentae, the placenta tears away from the wall of the uterus before delivery; the client usually has pain and a boardlike uterus. Preterm labor is associated with contractions and shouldn’t involve bright red bleeding. By definition, threatened abortion occurs during the first 20 weeks of gestation.

Nursing process step: Analysis

Correct answer-C. Rationales: The left lateral recumbent position avoids compression of the inferior vena cava; compressing the vessel may result in decreased uterine blood flow, fetal hypoxia, and maternal hypotension. Trendelenburg’s or the flat position would compress this vessel. If a pregnant client must lie flat on a backboard for cervical spine evaluation, a wedge may be placed under the right hip to avoid compressing the vessel. If the umbilical cord is prolapsed, the knee-chest position may be used to avoid compressing the cord.

Nursing process step: Intervention

Correct answer—A. Rationales: A pelvic examination shouldn’t be performed on a pregnant client with vaginal bleeding. In cases of placenta previa, the examination could cause further bleeding and damage the placenta. A client with placenta previa should be placed on bed rest and pad count and be monitored for signs of shock if bleeding is heavy and persists. A pelvic ultrasound is useful for detecting placenta previa. The client’s bladder should be filled using an indwelling urinary catheter rather than by mouth if cesarean birth is planned or if it’s suspected she may require cesarean delivery. In most cases, bed rest and pelvic rest stop the bleeding in a client with placenta previa.

Nursing process step: Intervention

Correct answer—C. Rationales: A client with pregnancy-associated hypertension complains of headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions aren’t associated with pregnancy-associated hypertension.

Nursing process step: Assessment

Correct answer-C. Rationales: Manual pressure is applied to the baby’s head by gently pushing up with the fingers to relieve pressure on the umbilical cord. This intervention is effective if the cord begins to pulsate. The mother may also be placed in the knee-chest or Trendelenburg position to ensure blood flow to the baby. Applying manual pressure isn’t done to slow the delivery process. A prolapsed cord necessitates an emergency cesarean birth. The nurse shouldn’t attempt to reinsert the umbilical cord because this would further compromise blood flow. At this point, the membranes are probably ruptured.

Nursing process step: Evaluation