While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital.
The nurse's teaching was effective when the patient states that she will come when she:
Feels increased fetal movement.
Thinks her membranes have ruptured.
Has contractions that are 10 minutes apart.
Has mild abdominal or groin discomfort.
The Correct Answer is B
Choice A rationale
Increased fetal movement is normal and usually not a sign to head to the hospital unless there are other concerns.
Choice B rationale
Ruptured membranes can signify the beginning of labor or risk for infection, warranting a visit to the hospital for assessment.
Choice C rationale
Contractions that are 10 minutes apart typically indicate early labor, but not necessarily the need to go to the hospital immediately.
Choice D rationale
Mild abdominal or groin discomfort can occur during pregnancy and does not immediately warrant a hospital visit without other signs of labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for correct condition: The client presents with a history of chronic hypertension, headache, visual disturbances, upper abdominal discomfort, and elevated blood pressure. Diagnostic results show elevated uric acid, proteinuria, and decreased platelet count. Physical examination reveals facial swelling, trace pitting edema, and hyperreflexia with clonus. These findings indicate preeclampsia, a condition of elevated blood pressure and proteinuria after 20 weeks of gestation. Preeclampsia may lead to severe complications if untreated.
Rationale for actions:
- Administering magnesium sulfate helps prevent seizures associated with severe preeclampsia.
- Preparing for immediate delivery is necessary if preeclampsia poses a severe risk to the mother or fetus.
Rationale for parameters:
- Monitoring blood pressure trends is crucial to manage and prevent severe hypertensive complications.
- Checking platelet count helps detect worsening coagulopathy, which is common in preeclampsia.
Rationale for incorrect conditions:
- Gestational hypertension: It lacks proteinuria and does not fully account for symptoms like severe headache and visual disturbances.
- HELLP syndrome: Although it shares similarities, HELLP would present with more severe hemolysis and liver involvement.
- Placental abruption: This condition would present with vaginal bleeding and abdominal pain, which are not reported in this case.
Correct Answer is D
Explanation
Choice A rationale
Administering oxytocin is not appropriate at this stage since the fetal head at a +5 station indicates imminent delivery.
Choice B rationale
Applying fundal pressure is not recommended and can cause complications such as uterine rupture or maternal injury.
Choice C rationale
Suctioning the mouth of the infant at the perineum should be done only after the head is delivered to clear airway obstructions.
Choice D rationale
Observing for the presence of a nuchal cord is crucial as it can cause complications during delivery, requiring immediate attention.
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