A client at 28 weeks of gestation presents with bleeding from the vagina.
Which assessment finding should the nurse prioritize?
Regular uterine contractions occurring every 15 minutes
Low back pain and pelvic pressure
Change in vaginal discharge
Rupture of membranes
The Correct Answer is A
Regular uterine contractions occurring every 15 minutes.
This finding suggests that the client may have placental abruption, which is a serious complication that requires immediate medical attention. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause heavy bleeding, pain, and fetal distress.
Choice B is wrong because low back pain and pelvic pressure are common symptoms of preterm labor, which is not as urgent as placental abruption.
Choice C is wrong because a change in vaginal discharge is not a specific sign of any complication and may be normal in pregnancy.
Choice D is wrong because rupture of membranes is not a priority finding in this case, unless it is associated with infection or cord prolapse.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Pre-term newborns are at risk of apnea of prematurity, which is a pause in breathing for more than 20 seconds or less than 20 seconds with bradycardia or cyanosis.An apnea monitor can detect and alert the parents of any episodes of apnea and help them intervene promptly.
Choice A is wrong because breastfeeding is beneficial for pre-term newborns and can provide them with antibodies, nutrients, and bonding with the mother.Breastfeeding should be encouraged as soon as the newborn is medically stable and able to suck and swallow.
Choice C is wrong because keeping the newborn in a warm environment at all times can lead to overheating, dehydration, and increased metabolic rate.Pre-term newborns have difficulty regulating their body temperature and need to be dressed appropriately for the ambient temperature.They should also be monitored for signs of cold stress or heat stress.
Choice D is wrong because delaying immunizations until the newborn reaches term gestation can expose the newborn to preventable infections that ...
Correct Answer is A
Explanation
Assess fetal heart rate and activity.
The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.
Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.
Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.
Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.
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