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.
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Correct Answer is B
Explanation
Drinking enough water can help prevent dehydration, which can trigger preterm labor contractions.Dehydration can also cause low amniotic fluid levels, which can affect fetal growth and development.
Choice A is wrong because avoiding sexual intercourse until term is not necessary for most women at risk for preterm labor.Sexual activity does not cause preterm labor unless there are other complications, such as placenta previa or cervical insufficiency.
Choice C is wrong because lying down when feeling contractions may not stop preterm labor.If a woman has regular contractions that cause cervical change, she should seek medical attention as soon as possible.Lying down may also reduce blood flow to the uterus and placenta, which can affect fetal oxygenation.
Choice D is wrong because taking aspirin for pelvic pain is not recommended for pregnant women.Aspirin can increase the risk of bleeding and affect fetal blood circulation.
Pelvic pain may be a sign of preterm labor or other complications, so it should be evaluated by a health care provider
Correct Answer is D
Explanation
All of the above.The nurse should include all of these signs and symptoms in the teaching as they may indicate pre-term labor.Pre-term labor occurs when regular contractions begin to open the cervix before 37 weeks of pregnancy.
Choice A is wrong because decreased fetal movement is not a normal sign of pre-term labor, but it may indicate fetal distress or other complications.
Choice B is wrong because increased vaginal discharge is not a normal sign of pre-term labor, but it may indicate infection or rupture of membranes.
Choice C is wrong because pelvic pressure is not a normal sign of pre-term labor, but it may indicate cervical dilation or descent of the fetus.
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