A nurse is assessing a 32-year-old gravida 3, para 2 client at 10 weeks gestation who presents with vaginal bleeding and severe nausea and vomiting. Which assessment finding would be most characteristic of a hydatidiform mole?
A 28-year-old primigravida at 12 weeks gestation presents to the emergency department with complaints of severe nausea, vomiting, and vaginal spotting that started 2 days ago. She reports that her morning sickness has been much worse than what her friends experienced during their pregnancies.
1Fetal heart tones detected at 140 beats per minute
2Fundal height measuring larger than expected for gestational age✓ 정답
3Blood pressure of 110/70 mmHg
4Hemoglobin level of 11.5 g/dL
해설
Hydatidiform mole is characterized by fundal height larger than expected for gestational age due to rapid uterine growth from proliferating trophoblastic tissue. Other findings like fetal heart tones or normal vital signs are not characteristic.
Core Nursing ExplanationKey Concept Analysis: This question assesses the ability to identify the classic clinical sign of a Hydatidiform mole (Molar pregnancy). A molar pregnancy is a type of Gestational Trophoblastic Disease (GTD) where abnormal fertilization leads to the proliferation of trophoblastic tissue (which normally forms the placenta) into grapelike vesicles, with no viable fetus. The core pathophysiology involves rapid, abnormal growth of this tissue, causing the uterus to enlarge at a rate faster than a normal pregnancy.
Answer Rationale: Key Point! The most characteristic finding is Fundal height measuring larger than expected for gestational age. This is a direct result of the rapid proliferation of the abnormal trophoblastic tissue filling the uterus. In a normal pregnancy at 10-12 weeks, the fundus is typically just at or above the pubic symphysis. With a molar pregnancy, it can be significantly higher, such as measuring like a 16-20 week pregnancy.
Distractor Analysis:
Watch out for confusion! Option 1: Fetal heart tones detected. This is incorrect because a complete molar pregnancy has no fetal development. The presence of fetal heart tones would indicate a viable pregnancy or a different condition (like a partial mole with some fetal tissue, but even then, FHTs are often absent or abnormal).
Option 3: A Blood pressure of 110/70 mmHg is within the normal range. While preeclampsia (characterized by hypertension) is a known risk associated with molar pregnancies, it typically develops later (after 20 weeks). A normal BP does not rule out a mole, nor is it a characteristic finding.
Option 4: A Hemoglobin level of 11.5 g/dL is at the lower end of normal for pregnancy but is not diagnostic. Vaginal bleeding from a mole can lead to anemia, but this is a non-specific finding. The hallmark is the discrepancy between uterine size and dates.
Related Concepts: Other classic signs of a hydatidiform mole include: passage of grapelike vesicles from the vagina, markedly elevated levels of human chorionic gonadotropin (hCG) (often much higher than expected for dates), hyperemesis gravidarum (severe nausea/vomiting) due to the high hCG, and early-onset preeclampsia. The definitive diagnosis is made by ultrasound showing a "snowstorm" or "cluster of grapes" appearance and the absence of a fetus.
Concept Summary Hydatidiform Mole (Molar Pregnancy): Abnormal proliferation of trophoblastic tissue, forming vesicles.
Pathognomonic Sign: Uterine size > dates (Fundal height larger than expected).
Key Symptom Triad: 1) Vaginal bleeding (often dark brown, "prune juice"), 2) Excessive uterine enlargement, 3) Hyperemesis gravidarum.
Diagnostic Clue: Extremely high serum beta-hCG levels.
Definitive Diagnosis: Pelvic ultrasound showing characteristic vesicular pattern.
Critical Complication: Can develop into invasive mole or choriocarcinoma (a malignant form of GTD).
Side-by-Side Comparison!
Feature
Normal Early Pregnancy
Hydatidiform Mole
Threatened Abortion
Uterine Size
Consistent with dates
Larger than dates
Consistent or smaller
Vaginal Bleeding
Minimal spotting possible
Common, may pass vesicles
Present, variable amount
hCG Level
Doubles approx. every 48 hrs
Extremely High
May be low or declining
Nausea/Vomiting
Common ("morning sickness")
Often Severe (Hyperemesis)
Variable
Ultrasound Findings
Gestational sac, fetal pole
"Snowstorm" pattern, no fetus
May show viable fetus or empty sac
Anatomy, Physiology & Pharmacology Points Pathophysiology: In a complete mole, an empty egg is fertilized by one sperm that duplicates (46,XX all paternal) or by two sperm. The placenta (trophoblast) grows abnormally, but there is no fetal tissue. This tissue secretes massive amounts of hCG.
hCG Role: Human Chorionic Gonadotropin is the hormone detected in pregnancy tests. Its excessive production in a mole directly causes severe nausea/vomiting and can lead to theca lutein ovarian cysts.
Treatment & Follow-up: Treatment is uterine evacuation via Dilation and Curettage (D&C). Post-evacuation, serial hCG levels are monitored weekly until normal for 3 weeks, then monthly for 6-12 months. The patient must avoid pregnancy during this time to ensure hCG levels are from the mole, not a new pregnancy.
Memory Tips Mnemonic: LARGE & NAUSEOUS Larger uterus than dates
Absent fetal heart tones
Rapid growth
Grapelike vesicles passed
Elevated hCG (Extreme)
& Nausea/vomiting (severe)
Anemia (from bleeding)
Ultrasound shows "snowstorm"
Spotting/bleeding
Ovarian cysts (theca lutein)
Usually no fetus
Serial hCG monitoring needed
High-Frequency NCLEX Topics
The NCLEX loves to test the classic triad of molar pregnancy: Vaginal bleeding + Uterine size > dates + High hCG. They also frequently ask about post-treatment care and teaching, especially the importance of serial hCG monitoring and pregnancy prevention for 6-12 months to detect potential choriocarcinoma.
Watch Out for Question Variations!
Instead of asking for a sign, they may ask: "The nurse is reviewing the lab results for a client with suspected hydatidiform mole. Which finding should the nurse anticipate?" Answer: Serum hCG level of 500,000 mIU/mL.
They may present a scenario post-D&C and ask for priority teaching: "Which instruction is most important for the client after evacuation of a hydatidiform mole?" Answer: "You will need to have your blood drawn regularly to check hCG levels and must use reliable contraception."
They could ask about a complication: "A client with a recent molar pregnancy presents with dyspnea and cough. The nurse should suspect..." Answer: Metastasis to the lungs (a sign of choriocarcinoma).
Nursing Clinical Practice GuideClinical Scenario: You are a nurse in the OB-GYN clinic. Ms. Chen, a 28-year-old G1P0 at 12 weeks by LMP, presents for her first prenatal visit. She reports intense nausea and vomiting for the past 4 weeks, requiring multiple ER visits for IV fluids. She also mentions intermittent dark brown vaginal spotting. On assessment, her fundal height measures 18 cm (consistent with an 18-week size). Her urine pregnancy test is strongly positive.
Nursing Intervention Strategy:
1. Assessment: Perform a comprehensive assessment. Document vital signs (watch for early signs of preeclampsia like rising BP). Perform a focused abdominal assessment: measure fundal height meticulously. Ask detailed questions about the character of vaginal bleeding (color, amount, presence of any tissue or grapelike material). Assess for signs of dehydration from hyperemesis (skin turgor, mucous membranes, urine output).
2. Support & Preparation: Provide emotional support. The client may be excited about her pregnancy and this news can be devastating. Explain that the physician will likely order a transvaginal ultrasound and quantitative serum beta-hCG test to get more information. Prepare her for the possibility of a diagnosis other than a normal pregnancy.
3. Post-Diagnosis Care: If a molar pregnancy is confirmed, the primary nursing role shifts to pre- and post-procedure care for the D&C. Monitor for complications of the procedure (hemorrhage, infection, uterine perforation). The most critical nursing responsibility begins after the procedure: patient education.
Patient Safety and Precautions:
Contraindication: Do NOT attempt to induce labor with oxytocics for a molar pregnancy, as it increases the risk of trophoblastic embolization.
Medication Caution: Manage hyperemesis with antiemetics as ordered, but understand the root cause is the high hCG, which will resolve after evacuation.
Key Monitoring Points: Post-evacuation, monitor for signs of hemorrhage (increased vaginal bleeding, tachycardia, hypotension) and infection (fever, foul-smelling discharge, uterine tenderness).
Nursing Procedure & Medication FlowProcedure: Assisting with Dilation & Curettage (D&C)
1. Verify informed consent is obtained.
2. Ensure NPO status as ordered.
3. Establish IV access for fluids and possible medication administration.
4. Assist the client into the lithotomy position.
5. Provide perineal antiseptic cleansing as per protocol.
6. Monitor vital signs throughout the procedure.
7. Post-procedure: Monitor in recovery for 1-2 hours. Assess vaginal pad count for bleeding. Provide perineal care instructions.
Patient Education Flow (Post-Evacuation):
1. Serial hCG Monitoring: "You will need weekly blood tests until your hCG level is normal for 3 consecutive weeks. After that, we check it monthly for 6 to 12 months."
2. Contraception: "It is extremely important to not get pregnant during this follow-up period. We need to be sure any hCG in your blood is from the mole resolving, not a new pregnancy. Use a reliable method like oral contraceptives or an IUD."
3. Warning Signs: "Report any of these to your doctor immediately: return of vaginal bleeding, persistent nausea/vomiting, cough or shortness of breath, or a positive home pregnancy test."
A Word from Your Senior Nurse
"Molar pregnancies are emotionally challenging for patients and families who were expecting a baby. As a nurse, your empathy and clear, confident education are as vital as your clinical skills. Remember the mantra: 'Size > Dates, Think Moles.' Catching this early ensures proper treatment and monitoring to prevent the serious complication of choriocarcinoma. When you teach a patient about the importance of those serial hCG draws, you're not just giving instructions—you're empowering her to be an active participant in safeguarding her own long-term health. That's the heart of nursing."
Hydatidiform Mole — A benign tumor of the chorionic villi, resulting in abnormal placental development with grapelike vesicles and no viable fetus.
Fundal Height — A measurement from the top of the pubic bone to the top of the uterus (fundus), used to assess fetal growth and uterine size in pregnancy.
Human Chorionic Gonadotropin — A hormone produced by the placenta during pregnancy. Levels are abnormally high in molar pregnancies.
Hyperemesis Gravidarum — Severe, persistent nausea and vomiting during pregnancy leading to weight loss, dehydration, and electrolyte imbalance; commonly associated with molar pregnancy.
Dilation and Curettage (D&C) — A surgical procedure to remove tissue from the inside of the uterus; the primary treatment for a hydatidiform mole.