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 D
Explanation
A. Heart rate of 55/min. A heart rate of 55/min is bradycardia, which may indicate magnesium toxicity. This is a concerning sign and does not indicate safety to continue.
B. Urine output of 50 mL in 4 hr. A urine output of only 50 mL in 4 hours is too low (less than 30 mL/hr is concerning) and may indicate toxicity, since magnesium sulfate is excreted via the kidneys.
C. Diminished deep-tendon reflexes. Diminished deep-tendon reflexes (DTRs) may indicate magnesium toxicity. DTRs are monitored to assess for toxicity.
D. Respiratory rate of 16/min. A normal respiratory rate (12-20 breaths per minute) indicates that the magnesium sulfate has not caused respiratory depression, a sign of magnesium toxicity.
Correct Answer is D
Explanation
A. "Count the fetal heart rate for 15 seconds to determine the baseline." The fetal heart rate (FHR) should be counted for a full minute to determine the baseline, not just for 15 seconds.
B. "Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor." The fetal heart rate is typically auscultated every 30 minutes in low-risk clients during the first stage of labor.
C. "Auscultate the fetal heart rate every 30 minutes during the second stage of labor." The fetal heart rate should be auscultated every 15 minutes during the second stage of labor, not every 30 minutes.
D. "Count the fetal heart rate after a contraction to determine baseline changes." It is important to assess the fetal heart rate after a contraction to determine if there are any decelerations or baseline changes that may indicate fetal distress.
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