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

Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.

Choice B rationale

Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.

Choice C rationale

While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.

Choice D rationale

Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.

A. Hyperglycemia B. Anemia C. Type 1 diabetes mellitus D. Hypertension

Correct Answer is D

Explanation

Choice A rationale

Hyperglycemia, or high blood sugar, is a condition that is most commonly seen in individuals with diabetes. Symptoms can include frequent urination, increased thirst, and increased hunger. If left untreated, it can lead to serious complications such as diabetic ketoacidosis.

Choice B rationale

Anemia is a condition characterized by a decrease in the total amount of red blood cells or hemoglobin in the blood, or a lowered ability of the blood to carry oxygen. Symptoms can include fatigue, weakness, pale or yellowish skin, irregular heartbeats, shortness of breath, dizziness or lightheadedness, and chest pain.

Choice C rationale

Type 1 diabetes mellitus is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs when the body becomes resistant to insulin or doesn’t make enough insulin.

Choice D rationale

Hypertension, or high blood pressure, is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. If the nurse is reviewing the client’s medical records and actions to be taken, it is likely that the client is experiencing hypertension.

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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 administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has just been admitted to the medical-surgical unit from the emergency department.The nurse is reviewing the client’s medical records.Which of the following conditions is the client most likely experiencing, based on the client’s notes and actions to be taken?

Correct Answer is D

Explanation

A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption.The nurse should recognize that which of the following is the most common risk factor for abruption?

A nurse is caring for four clients who have various types of drainage tubes.Which of the following clients should the nurse identify as being at risk for hypokalemia?

A nurse is assessing a newborn 1 hour after birth.The nurse recognizes that which of the following respiratory rates is within the expected reference range for a newborn?

A nurse is educating a group of patients in their first trimester about exercise during pregnancy.Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client diagnosed with gastrointestinal bleeding.Which of the following actions should the nurse take first?

As a nurse caring for a group of clients on an intrapartum unit, which of the following findings should be immediately reported to the provider?

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