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

Frothy pink drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as pulmonary edema where the fluid from the lungs can sometimes appear frothy and pink.

Choice B rationale

Coffee-ground drainage is a common finding in patients with an active upper gastrointestinal bleed. When blood mixes with gastric acid, it can create a substance that resembles coffee grounds. This is often seen when a nasogastric (NG) tube is inserted into the patient.

Choice C rationale

Dark amber drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as liver disease where the urine can sometimes appear dark amber.

Choice D rationale

Greenish-yellow drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as bile duct obstruction where the bile can sometimes appear greenish-yellow.

A. “I should not get pregnant for at least 4-12 weeks after the vaccine.”. B. “I need another shot after each baby I have with Rh-positive blood.”. C. “I need another shot in 1 month and again in 6 months.”. D. “This shot may cause a fever and make me vomit.”.

Correct Answer is A

Explanation

Choice A rationale

The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.

Choice B rationale

This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.

Choice C rationale

This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.

Choice D rationale

While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.

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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 patient who has an active upper gastrointestinal bleed.After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?

Correct Answer is B

Explanation

A client’s prenatal laboratory findings reveal no immunity to rubella.The health care provider orders the rubella vaccine.The nurse concludes that teaching about this medication is effective when the client states which of the following?

Correct Answer is A

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?