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 []
Explanation
The client’s symptoms—severe chest pain, nausea, dizziness, trembling, and diaphoresis—along with elevated troponin levels, are indicative of a myocardial infarction. Troponin is a cardiac biomarker used to diagnose myocardial infarction, and the client’s symptoms are consistent with this condition.
Actions to Take:
- Use Therapeutic Communication to Build Rapport
Effective therapeutic communication helps the client feel supported and may reduce anxiety and fear related to their condition. This approach can provide a calm environment for the client, which is crucial when managing a myocardial infarction. - Teach Coping Skills
Teaching coping skills can help the client manage anxiety and stress, which are important for recovery from a myocardial infarction. Understanding how to cope with the emotional and psychological aspects of the condition supports overall care and management.
Parameters to Monitor:
- Heart Rhythm
Monitoring heart rhythm is essential to detect any arrhythmias or complications related to myocardial infarction. Changes in heart rhythm can indicate worsening of the condition or response to treatment. - Vital Signs
Monitoring vital signs, including blood pressure and heart rate, is crucial for assessing the client’s hemodynamic status and the effectiveness of treatment. Abnormalities in vital signs can indicate worsening of the myocardial infarction or side effects of medications
Correct Answer is D
Explanation
A. Missing the child every day is a normal part of the grieving process but does not indicate improvement in managing depression.
B. Drinking 4 to 6 bottles of beer each evening suggests the client may be using alcohol as a coping mechanism, indicating poor management of depression.
C. Expressing that drunk driving is inexcusable shows the client has a strong opinion on the matter, but it does not necessarily indicate improvement in the client’s emotional health.
D. Sleeping through the night often indicates an improvement in the client’s ability to rest and manage depressive symptoms, suggesting a positive response to treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.