A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.
What should be the appropriate response by the nurse?

“We can wait until your next appointment to check you.”.

“As long as the baby is still moving around, there is nothing to worry about.”.

“Go to the hospital right away.”.

“Call back in 2 hours and tell me if there is any change in the leakage.”.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Waiting until the next appointment could potentially put both the mother and the baby at risk. Leakage of vaginal fluid could indicate premature rupture of membranes, which can lead to infection or premature labor.

Choice B rationale

While fetal movement is a good sign, it does not rule out potential complications associated with leakage of vaginal fluid. Therefore, this advice could lead to a delay in necessary medical intervention.

Choice C rationale

This is the most appropriate response. Leakage of vaginal fluid in a pregnant woman could be a sign of premature rupture of membranes, which can lead to complications such as infection or premature labor. Immediate medical attention is necessary to assess the situation and take appropriate action.

Choice D rationale

Asking the client to wait and see if the leakage changes could potentially delay necessary medical intervention. It’s important to seek immediate medical attention to assess the situation and take appropriate action.

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Correct Answer is A

Explanation

Choice A rationale

A client diagnosed with preeclampsia reporting epigastric pain and unresolved headache is a serious concern. Epigastric pain could indicate severe liver involvement, and a persistent headache could be a sign of progressing neurological involvement, both of which are severe features of preeclampsia. These symptoms suggest the condition may be worsening to eclampsia, a life-threatening complication characterized by the onset of seizure activity or coma in a woman with preeclampsia. Immediate medical attention is necessary to prevent further complications.

Choice B rationale

A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing preterm labor. However, emotional distress and contractions do not necessarily indicate a medical emergency. It’s important to monitor the situation, but it does not need to be immediately reported to the provider.

Choice C rationale

A client diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes are expected findings. Proteinuria is a common sign of preeclampsia, and hyperreflexia can occur due to increased neuromuscular irritability. While these should be monitored, they do not need to be immediately reported to the provider.

Choice D rationale

A client at 28 weeks of gestation receiving terbutaline reporting fine tremors is an expected side effect of the medication. Terbutaline, a beta-adrenergic agonist, can cause tremors by stimulating the nervous system. While it may be uncomfortable for the client, it is not a medical emergency.

A. Call the Doctor. B. Administer diazepam. C. Obtain a medical history. D. Raise the side rails of the bed.

Correct Answer is B

Explanation

Choice A rationale

While it is important to notify the doctor, it is not the first action. The priority is to manage the patient’s symptoms and ensure their safety.

Choice B rationale

Administering diazepam is the correct first action. Delirium tremens is a severe form of alcohol withdrawal that can cause dangerous changes in breathing, blood pressure, and heart rate. Benzodiazepines like diazepam are the first line of treatment.

Choice C rationale

Obtaining a medical history is important, but it is not the first action. The priority is to treat the patient’s symptoms and stabilize their condition.

Choice D rationale

Raising the side rails of the bed is important for patient safety, but it is not the first action. The priority is to treat the patient’s symptoms. Diabetic ketoacidosisDiabetic ketoacidosis Explore

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A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.What should be the appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.
What should be the appropriate response by the nurse?