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 ["B","D","E","F"]
Explanation
A. A warning about potential charges for child neglect
This is not appropriate in a pre-discharge education context. The focus should be on providing support and education to prevent future incidents and to help the parents understand the importance of supervision and safety.
B. Information about pool safety
Providing information about pool safety is essential to prevent future drowning incidents. Parents should be educated on supervision, barriers, and emergency response measures like CPR. This helps ensure the child's safety and reduces the risk of similar accidents.
C. Instructions on how to access long-term home care
Long-term home care instructions are unnecessary unless the child has specific ongoing medical needs resulting from the submersion. Since the child is showing only minor signs of impact, this education is not relevant.
D. When to follow up with the child's pediatrician
Clear instructions on when to follow up with the pediatrician ensure ongoing monitoring for any delayed effects of the submersion injury. This follow-up helps address any emerging health concerns and reassures the parents about their child's recovery.
E. Assessment of the parent's coping skills
Assessing the parents' coping skills is important to understand their emotional and psychological state post-incident. This can help identify any need for further support or counseling, ensuring the family is equipped to handle the situation.
F. Contact information for community resources
Providing contact information for community resources offers additional support to the parents, such as access to counseling, parenting classes, or safety courses. This reinforces the safety education provided and ensures the parents have resources to turn to if needed
Correct Answer is D
Explanation
A. Exploring the client’s thoughts about dying is supportive but not the immediate priority when a specific request for a religious ritual is made.
B. Notifying the family of the request is a secondary action but should follow the immediate fulfillment of the client's request for spiritual support.
C. Suggesting that the hospital chaplain is available might be appropriate, but the client's specific request was for a priest, and it is better to offer to contact the priest directly.
D. Offering to contact the priest for the client directly addresses the client's immediate spiritual need and respects their request.
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