During a routine prenatal visit, a client at 32-weeks gestation reports that urinary frequency has increased during the day as well as at night. The nurse determines the client is having irregular uterine contractions. Which action should the nurse implement?

Collect a urine sample for dipstick analysis.

Ask the client if she had sexual intercourse yesterday.

Obtain a midstream urine specimen for culture.

Determine if she has a change in vaginal discharge.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Collecting a urine sample for dipstick analysis can identify urinary tract infections (UTIs) or other abnormalities. Dipstick tests detect leukocytes, nitrites, protein, and glucose, providing rapid results for initial screening of urinary issues.

Choice B rationale

Asking the client if she had sexual intercourse yesterday may help identify potential causes of urinary frequency, such as post-coital irritation. However, it does not directly address the irregular uterine contractions or possible infections.

Choice C rationale

Obtaining a midstream urine specimen for culture is crucial for diagnosing UTIs, which can cause urinary frequency and uterine irritability. Culturing urine identifies specific pathogens, guiding targeted antibiotic therapy to treat the infection.

Choice D rationale

Determining if she has a change in vaginal discharge can indicate infections or other conditions affecting the reproductive tract. However, it does not directly address the urinary frequency or irregular uterine contractions, making it less immediate.

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Correct Answer is C

Explanation

Choice A rationale

Administering acetaminophen is not indicated as the temperature of 100.4° F (38° C) is within the normal postpartum range, often due to dehydration or breast engorgement. Acetaminophen should be used cautiously and only if necessary.

Choice B rationale

Assessing perineum for excessive lochia is unnecessary here, as the current vital signs do not indicate hemorrhage. Normal postpartum bleeding gradually decreases in amount and should be monitored accordingly but not prompted by these vitals.

Choice C rationale

Documentation of vital signs is essential to maintain accurate medical records and track any changes in the patient's condition. Accurate records help in identifying trends and making informed decisions about patient care.

Choice D rationale

Reporting a heart rate of 58 beats/minute is unnecessary because bradycardia can be normal in postpartum women, especially if they have good cardiovascular fitness. It is important to monitor for other symptoms before taking further action.

A. Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry. B. Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C). C. Monitor temperature. D. Continue to monitor glucose levels. E. Explain to the mother that the baby’s respiratory rate needs to be below 60 breaths/minute to be able to breastfeed. F. Tell the mother that she will need to discuss any concerns with the neonatologist. G. Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Monitoring for respiratory distress and checking oxygenation by pulse oximetry are critical in newborns, as they can indicate hypoxemia or respiratory issues requiring prompt intervention.

Choice B rationale

Maintaining the infant's temperature at 97.6°F (36.4°C) using a warmer and bilirubin lights is essential for thermoregulation and treating jaundice, ensuring proper physiological stability.

Choice C rationale

Regular temperature monitoring is vital to detect any signs of hypothermia or hyperthermia, which can indicate underlying health issues and guide appropriate interventions for the newborn.

Choice D rationale

Continued monitoring of glucose levels is crucial for detecting hypoglycemia, a common condition in newborns that can lead to seizures, brain damage, or other severe complications if left untreated.

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During a routine prenatal visit, a client at 32-weeks gestation reports that urinary frequency has increased during the day as well as at night. The nurse determines the client is having irregular uterine contractions. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

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