A client who is primigravida at term comes to the prenatal clinic and tells the practical nurse (PN) that she is having contractions every 5 minutes. The PN monitors the client for one hour using an external fetal monitor, and determines that the client's contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. Which action should the PN take?
Tell the client to go directly to the hospital for admission to labor and delivery for active labor.
Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour.
Direct the client to check into the hospital within the next hour for evaluation of possible urinary tract infection.
Send the client home and tell her to drink at least 1,000 mL of fluid each day to flush her bladder.
The Correct Answer is B
A. The client's contractions are not regular or intense enough to indicate active labor, so immediate hospital admission is not necessary.
B. Instructing the client to call the clinic when her contractions occur 5 minutes apart for one hour ensures she is monitored for the progression of labor and can seek timely assistance when labor becomes more active.
C. While a urinary tract infection could cause contractions, the primary focus should be on monitoring labor progression, not diagnosing a UTI at this stage.
D. Hydration is important, but the primary instruction should relate to monitoring contraction patterns for signs of active labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Response 1
A. Fluid volume deficit
The client has signs of dehydration such as dry mucous membranes and a recent history of not having much to eat or drink in the past 2 days, which indicates a fluid volume deficit.
B. Respiratory alkalosis
There is no evidence to support respiratory alkalosis. The client's primary issues are related to infection and dehydration.
C. Hypoxia
The client’s oxygen saturation is 100% on 2 L/minute nasal cannula, so hypoxia is not a current issue.
D. Diarrhea
Diarrhea is not mentioned in the history, symptoms, or findings. It is not relevant to the client's condition.
Response 2
A. Decreased fluid intake
The client has not had much to eat or drink in the past 2 days, contributing directly to the fluid volume deficit.
B. Increased respiratory rate
While the client has an increased respiratory rate, it is a symptom of pneumonia rather than a cause of fluid volume deficit.
C. Infection
Although the client has pneumonia, the fluid volume deficit is more directly related to decreased fluid intake than to infection.
D. Heart disease
Heart disease is not mentioned and is not relevant to the client’s current presentation.
Correct Answer is C
Explanation
A. Pallor is not directly related to low serum calcium levels. It may indicate anemia or other conditions, but it is not a primary concern for hypocalcemia.
B. Bruising is generally associated with clotting issues or trauma, not specifically with low serum calcium. Low calcium can affect clotting, but bruising is not a direct or primary symptom of hypocalcemia.
C. Tetany, which includes symptoms like muscle spasms, twitching, and numbness, is a key indicator of low serum calcium levels. Monitoring for tetany is essential in managing clients with malabsorption syndrome who have hypocalcemia.
D. Jaundice is a sign of liver dysfunction or hemolysis, not directly related to low calcium levels. Low serum calcium is not typically associated with jaundice.
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