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 B

Explanation

Choice A rationale

A moderate amount of swelling is not normal during a testicular self-examination. Any swelling or lumps should be reported to a healthcare provider for further evaluation.

Choice B rationale

The testicles should indeed be examined after a bath or shower. The warmth of the water relaxes the scrotal sac and makes it easier to feel for any abnormalities. This is the correct answer.

Choice C rationale

The testicular self-examination should not be performed twice a week. It is recommended to perform the examination once a month.

Choice D rationale

Abnormalities are not detected by pinching the testicles. Instead, the testicles should be rolled gently between the fingers and thumb to feel for any lumps or bumps.

A. Increase the rate of maintenance IV infusion. B. Place the client in the lateral position. C. Administer oxygen using a nasal cannula. D. Elevate the client’s legs.

Correct Answer is B

Explanation

Choice A rationale

Increasing the rate of maintenance IV infusion is not the first action the nurse should take when observing that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. This pattern is known as late decelerations and is often associated with fetal hypoxemia due to insufficient placental perfusion.

Choice B rationale

The nurse should first place the client in the lateral position. This position can improve placental blood flow and may help to resolve the late decelerations.

Choice C rationale

Administering oxygen using a nasal cannula may be beneficial, but it is not the first action the nurse should take. The priority is to improve placental blood flow, which can be achieved by changing the client’s position.

Choice D rationale

Elevating the client’s legs is not the first action the nurse should take. This action would not directly address the issue of late decelerations.

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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

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Explanation

Correct Answer is B

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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?