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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Related Questions
Correct Answer is A
Explanation
Betamethasone is a corticosteroid that is given to pregnant women who are at risk of preterm delivery to enhance fetal lung maturity and prevent respiratory distress syndrome.It is usually given in two doses, 24 hours apart, and takes effect within 24 hours of administration.
Choice B.Magnesium sulfate is wrong because it is used to prevent seizures in women with severe preeclampsia or eclampsia, not to prevent respiratory distress syndrome.
Choice C.Nifedipine is wrong because it is a calcium channel blocker that is used to inhibit uterine contractions and prolong pregnancy in women with preterm labor, not to prevent respiratory distress syndrome.
Choice D.Indomethacin is wrong because it is a nonsteroidal anti-inflammatory drug that is used to inhibit prostaglandin synthesis and reduce uterine activity in women with preterm labor, not to prevent respiratory distress syndrome.However, it can also cause premature closure of the ductus arteriosus in the fetus and should be avoided after 32 weeks of gestation.
Normal ranges for gestational age are 37 to 42 weeks.
Preterm labor is defined as regular uterine contractions with cervical changes.
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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