A nurse is admitting a client who is in pre-term labor at 34 weeks of gestation and has ruptured membranes and oligohydramnios.
Which of the following actions should the nurse take first?
Administer IV fluids
Obtain a urine specimen
Assess fetal heart rate
Insert an indwelling urinary catheter
The Correct Answer is C
This is because assessing fetal heart rate is the most important action to take first when a client has prelabor rupture of membranes (PROM) at 34 weeks of gestation and oligohydramnios. Fetal heart rate can indicate fetal well-being, distress, or infection. Oligohydramnios can increase the risk of umbilical cord compression and fetal hypoxia.
Choice A is wrong because administering IV fluids is not the first priority in this situation. IV fluids may be given to prevent dehydration, enhance uterine blood flow, or augment labor, but they are not as urgent as assessing fetal heart rate.
Choice B is wrong because obtaining a urine specimen is not the first priority in this situation. A urine specimen may be obtained to check for infection, proteinuria, or glucose levels, but they are not as urgent as assessing fetal heart rate.
Choice D is wrong because inserting an indwelling urinary catheter is not the first priority in this situation. An indwelling urinary catheter may be inserted to monitor fluid balance, prevent bladder distension, or reduce the risk of infection, but they are not as urgent as assessing fetal heart rate.
Normal ranges for fetal heart rate are 110 to 160 beats per minute. Oligohydramnios is defined as an amniotic fluid index of less than 5 cm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Report any increase in vaginal discharge to the provider.This is because an increase in vaginal discharge can indicate an infection, which can trigger preterm labor or cause complications for the mother and the baby.
Choice A is wrong because sexual intercourse is not contraindicated for women who have preterm labor that was successfully stopped with tocolytic therapy, unless they have other risk factors such as placenta previa or ruptured membranes.
Choice B is wrong because drinking at least 3 L of fluids per day is not necessary for women who have preterm labor that was successfully stopped with tocolytic therapy, unless they have dehydration or oligohydramnios.
Choice D is wrong because pelvic floor exercises are not recommended for women who have preterm labor that was successfully stopped with tocolytic therapy, as they can increase uterine activity and cause contractions.
Tocolytic therapy is the use of drugs to delay delivery for a short time (up to 48 hours) if a woman begins labor too early in her pregnancy.
The purpose of tocolytic therapy is to allow time for the administration of corticosteroids or other medicine.
Correct Answer is C
Explanation
The therapeutic effect of magnesium sulfate is to inhibit uterine contractions and prevent or delay preterm labor.
By assessing uterine activity, the nurse can evaluate if the medication is working or not.
Choice A is wrong because measuring urine output is not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for toxicity and renal function.
Choice B is wrong because checking deep tendon reflexes is also not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for neuromuscular effects and toxicity.
Choice D is wrong because monitoring blood pressure is not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for cardiovascular effects and toxicity.
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