A nurse is reinforcing teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include?
Wipe from the back to front when performing perineal hygiene
Keep a daily record of fetal kick counts.
Avoid bubble bath solution when taking a tub bath.
Use a condom with sexual intercourse.
The Correct Answer is B
A. Wipe from the back to front when performing perineal hygiene: The correct method for perineal hygiene is to wipe front to back to reduce the risk of introducing bacteria into the vaginal area, especially in a client with PROM who is at risk for infection.
B. Keep a daily record of fetal kick counts: Monitoring fetal kick counts helps assess fetal well-being, particularly in a high-risk pregnancy like PROM at 26 weeks. It helps detect potential fetal distress early.
C. Avoid bubble bath solution when taking a tub bath: While avoiding bubble bath may help prevent irritation or infection, tub baths should be avoided entirely in cases of PROM to reduce the risk of ascending infection.
D. Use a condom with sexual intercourse. Sexual intercourse is contraindicated in clients with PROM due to the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An artifact on the printout is very common. Artifacts are more common with external fetal monitoring, not internal fetal monitoring.
B. Accurate information regarding FHR variability is not possible. Internal fetal monitoring provides more accurate information about fetal heart rate (FHR) variability compared to external monitoring.
C. It cannot provide data about the uterine resting tone. Internal monitoring can measure the uterine resting tone more accurately than external methods.
D. It is invasive and increases the risk for uterine infection. Internal fetal monitoring requires inserting a device into the uterus, making it invasive and increasing the risk of infection.
Correct Answer is B
Explanation
A. Presentation, latent phase, powers, position and attitude. While "presentation," "powers," and "position" are relevant, the "latent phase" is a stage of labor, not a factor that affects the labor process. "Attitude" refers to the fetal posture but does not cover the entire process.
B. Passenger, passageway, powers, position and psychological response: These five factors are key components that affect labor and birth: Passenger: The fetus and placenta. Passageway: The birth canal. Powers: The contractions. Position: The mother’s position during labor. Psychological response: The mother’s emotional state during labor.
C. Passenger, presentation, lie, attitude and station: These terms describe aspects of the fetus's position and movement, but they do not encompass all the factors affecting labor.
D. Passageway, presentation, powers, contractions and position: This is close, but "psychological response" is missing, which is one of the essential components affecting labor.
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