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 B
Explanation
A. Decreased maternal heart rate: Maternal heart rate usually stays the same or may increase slightly due to the physical exertion of labor, but it does not decrease as a sign of labor progression.
B. Increased intensity and frequency of contractions: The active phase of labor is characterized by more frequent and intense contractions that lead to continued cervical dilation and effacement.
C. Decreased cervical dilation: Cervical dilation increases during labor, particularly in the active phase. Decreased dilation is a sign of dysfunctional labor, not normal progress.
D. Decreased intensity and frequency of contractions: Decreasing contraction intensity and frequency would indicate a stall in labor or ineffective labor, not normal progress.
Correct Answer is A
Explanation
A. Place the client in a lateral position. Hypotension is a common side effect of epidural anesthesia. Positioning the client laterally helps improve venous return and cardiac output, which can help raise blood pressure.
B. Elevate the legs. Elevating the legs can help improve circulation, but it is not the first action. The priority is to position the client laterally to improve venous return.
C. Notify the provider. While the provider should be notified, the first action is to take immediate corrective measures to address hypotension.
D. Increase IV fluid rate. Increasing IV fluids helps combat hypotension, but it is secondary to positioning the client laterally to improve blood flow.
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