A nurse is caring for a client who is at 33 weeks of gestation and has pre-term labor.
The client reports a sudden gush of fluid from her vagina.
Which of the following actions should the nurse take first?
Assess fetal heart rate and activity
Perform a nitrazine test on the fluid
Administer oxytocin (Pitocin) IV infusion
Place the client in Trendelenburg position
The Correct Answer is A
Assess fetal heart rate and activity.
The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk for premature rupture of membranes (PROM), which can lead to infection, cord prolapse, and fetal distress. Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.
Choice B is wrong because performing a nitrazine test on the fluid is not the first action. A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.
Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation. Oxytocin is used to induce or augment labor, but it can cause uterine hyperstimulation, fetal distress, and placental abruption if given to a client who has PROM.
Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM. Trendelenburg position can increase the risk of cord prolapse and aspiration in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Decreased frequency and intensity of contractions indicates that the client’s condition is improving.Preterm labor occurs when regular contractions result in the opening of your cervix before 37 weeks of pregnancy.
If preterm labor can’t be stopped, your baby will be born early and may have health problems.
Choice B is wrong because increased cervical dilation and effacement means that the cervix is thinning and opening more, which are signs of labor progression.
Choice C is wrong because increased amount and color of vaginal discharge may indicate infection, bleeding, or rupture of membranes, which are complications of preterm labor.
Choice D is wrong because decreased fetal heart rate variability means that the baby’s heart rate is not changing much, which may indicate fetal distress or hypoxia.A normal fetal heart rate variability is between 6 and 25 beats per minute.
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.
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.