A client who is 32 weeks pregnant calls the clinic complaining of an increase in vaginal discharge, pelvic pressure, and low back and abdominal pain. Based on this information, what action will the nurse take?

Tell the client to take a warm shower, rest, and call back tomorrow.

Schedule an appointment for the client at the clinic tomorrow.

Instruct the client to drink cranberry juice and call if she experiences a fever.

Instruct the client to go to labor triage at the hospital for evaluation.

Answer and Explanation

The Correct Answer is D

A. Tell the client to take a warm shower, rest, and call back tomorrow. While rest and hydration can sometimes help with mild discomfort, this client’s symptoms—pelvic pressure, low back pain, abdominal pain, and increased vaginal discharge—are concerning for preterm labor and require immediate evaluation. Delaying care could increase the risk of preterm birth.

B. Schedule an appointment for the client at the clinic tomorrow. Waiting until the next day is not appropriate, as preterm labor is an urgent condition that needs immediate assessment to prevent premature birth. Prompt intervention may allow for tocolytic therapy or steroid administration to improve fetal lung maturity if preterm birth is imminent.

C. Instruct the client to drink cranberry juice and call if she experiences a fever. Cranberry juice is sometimes used to prevent urinary tract infections (UTIs), but this client’s symptoms are more indicative of preterm labor rather than an infection. Fever is not a defining symptom of preterm labor, and delaying care could result in complications.

D. Instruct the client to go to labor triage at the hospital for evaluation. This is the best response because the symptoms suggest possible preterm labor. Evaluation in the hospital can include cervical checks, fetal monitoring, and tests such as fetal fibronectin (fFN) to assess the risk of preterm birth. Immediate intervention can help delay labor and improve neonatal outcomes.

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Correct Answer is ["C","D","E"]

Explanation

A. Obtain equipment to start a 24-hour urine test on the patient. A 24-hour urine test is not necessary for placenta previa. It is more commonly used for preeclampsia to assess proteinuria, which is unrelated to placenta previa.

B. Obtain equipment for a manual pelvic exam. A manual pelvic exam is contraindicated in placenta previa because it can cause further disruption of the placenta, leading to severe hemorrhage. Instead, diagnosis should be confirmed using ultrasound.

C. Prepare to draw blood for a hemoglobin and hematocrit. Hemoglobin and hematocrit levels must be monitored due to the risk of maternal hemorrhage in placenta previa. Significant blood loss can lead to anemia and may require blood transfusions.

D. Obtain equipment for external electronic fetal heart rate monitoring. Continuous fetal monitoring is essential in placenta previa to assess for signs of fetal distress. External monitoring is preferred to avoid vaginal examinations, which could worsen bleeding.

E. Prepare the patient for an ultrasound. Ultrasound is the diagnostic test of choice for placenta previa. It helps determine the exact location of the placenta and confirms whether it is covering the cervix. A transabdominal ultrasound is performed first, followed by a transvaginal ultrasound if necessary.

A. Apply Oxygen B. Increase IV Pitocin C. Apply downward pressure on the woman's fundus D. Flex the woman's thighs sharply toward her abdomen

Correct Answer is D

Explanation

A. Apply oxygen. While oxygen may be administered if fetal distress is present, it does not directly resolve shoulder dystocia, which is a mechanical issue requiring immediate positional maneuvers to free the impacted shoulder.

B. Increase IV Pitocin. Increasing oxytocin (Pitocin) is contraindicated in shoulder dystocia because it can cause stronger contractions, worsening the impaction and increasing the risk of fetal injury or uterine rupture.

C. Apply downward pressure on the woman's fundus. Fundal pressure should never be applied in shoulder dystocia, as it can further wedge the fetal shoulder against the pubic bone, increasing the risk of brachial plexus injury and fetal distress.

D. Flex the woman's thighs sharply toward her abdomen. The McRoberts maneuver, which involves sharply flexing the mother’s thighs to widen the pelvic outlet, is the first-line intervention for shoulder dystocia. This maneuver helps rotate the pelvis and reposition the fetal shoulder, increasing the chances of a successful vaginal delivery.

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A client who is 32 weeks pregnant calls the clinic complaining of an increase in vaginal discharge, pelvic pressure, and low back and abdominal pain. Based on this information, what action will the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing for the admission of a 30 weeks' gestation patient experiencing vaginal bleeding with a suspected diagnosis of placenta previa. In anticipating the patient's needs, which of the following would be most appropriate for the nurse to include? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

During a vaginal delivery the midwife tells you that a shoulder dystocia has occurred. Which of the following initial nursing actions is appropriate at this time?

Correct Answer is D

Explanation

The nurse recognizes that a woman is in true labor when she states…., and finds that her cervix has dilated and effaced on examination.

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