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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Corticosteroids are given to pregnant women who are at risk of preterm labor to help mature the lungs of the fetus and reduce the risk of respiratory distress syndrome and other complications.Corticosteroids also have a protective effect on the brain and reduce the risk of bleeding and cerebral palsy.

Choice A is wrong because administering intravenous fluids is not a specific intervention to address possible outcomes and complications of preterm labor.Intravenous fluids may be given to correct dehydration or electrolyte imbalance, but they do not prevent or treat preterm labor.

Choice B is wrong because administering tocolytics is an intervention to delay preterm labor, not to address possible outcomes and complications.

Tocolytics are drugs that inhibit uterine contractions and prolong pregnancy for a short period of time, usually 24 to 48 hours, to allow for the administration of corticosteroids or the transfer of the mother to a facility with neonatal intensive care.

A. Asthma B. Diabetes mellitus C. Hypertension D. Cardiac disease

Correct Answer is D

Explanation

Nifedipine is a calcium channel blocker that is used to relax uterine contractions and postpone preterm labor.However, it can also lower blood pressure and cause side effects such as headache, dizziness, flushing, and palpitations.Therefore, it should be avoided in clients who have cardiac disease or other conditions that affect the heart function.

Choice A is wrong because asthma is not a contraindication for nifedipine.Nifedipine does not affect the airways or cause bronchospasm.

Choice B is wrong because diabetes mellitus is not a contraindication for nifedipine.Nifedipine does not affect blood glucose levels or insulin secretion.

Choice C is wrong because hypertension is not a contraindication for nifedipine.In fact, nifedipine can be used to treat high blood pressure as well as preterm labor.However, blood pressure should be monitored closely during nifedipine therapy to avoid hypotension.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client and her partner about pre-term labor. Which intervention should the nurse include in the teaching plan to address possible outcomes and complications?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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?