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 D

Explanation

Choice A rationale

Strabismus, or crossed eyes, is a condition that typically requires treatment and is not normal in newborns. It involves a lack of coordination between the muscles that control eye movement, causing the eyes to point in different directions.

Choice B rationale

While it’s important to report concerns to the primary care provider, this statement does not directly address the mother’s concern about her newborn’s crossed eyes.

Choice C rationale

Taking the baby to the nursery for further examination may be necessary in some cases, but it does not provide the mother with immediate reassurance or information about her newborn’s condition.

Choice D rationale

Newborns often lack the muscle control necessary to regulate eye movement, which can cause their eyes to cross. This is a normal part of development and typically resolves on its own within the first few months of life.

A. Restrict outdoor activity to 1 hour per day. B. Apply cold compresses when your child expresses pain. C. Drink fluids multiple times every day. D. Monitor your temperature daily.

Correct Answer is C

Explanation

Choice A rationale

Restricting outdoor activity to 1 hour per day is not necessary for patients with sickle cell anemia. While strenuous exercise and overexertion should be avoided, regular moderate exercise is beneficial and helps to promote good overall health.

Choice B rationale

Applying cold compresses when the child expresses pain is not recommended. Cold can lead to vasoconstriction, which can trigger a sickle cell crisis. Instead, warm compresses are often used to help increase circulation and reduce pain.

Choice C rationale

Drinking fluids multiple times every day is crucial. Hydration helps to keep the blood diluted and reduces the chances of a sickle cell crisis. Dehydration can increase the risk of a sickle cell crisis.

Choice D rationale

Monitoring temperature daily is not specifically required for patients with sickle cell anemia. However, any signs of infection, such as fever, should be reported to a healthcare provider immediately, as infection can trigger a sickle cell crisis.

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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

A nurse is caring for a new mother who is concerned that her newborn’s eyes cross.Which of the following statements is a therapeutic response by the nurse?

Correct Answer is D

Explanation

A nurse is preparing to discharge a patient who has sickle cell anemia following an acute crisis episode.Which instructions should the nurse include in the teaching?

Correct Answer is C

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?