A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.
What should be the appropriate response by the nurse?
“We can wait until your next appointment to check you.”.
“As long as the baby is still moving around, there is nothing to worry about.”.
“Go to the hospital right away.”.
“Call back in 2 hours and tell me if there is any change in the leakage.”.
The Correct Answer is C
Choice A rationale
Waiting until the next appointment could potentially put both the mother and the baby at risk. Leakage of vaginal fluid could indicate premature rupture of membranes, which can lead to infection or premature labor.
Choice B rationale
While fetal movement is a good sign, it does not rule out potential complications associated with leakage of vaginal fluid. Therefore, this advice could lead to a delay in necessary medical intervention.
Choice C rationale
This is the most appropriate response. Leakage of vaginal fluid in a pregnant woman could be a sign of premature rupture of membranes, which can lead to complications such as infection or premature labor. Immediate medical attention is necessary to assess the situation and take appropriate action.
Choice D rationale
Asking the client to wait and see if the leakage changes could potentially delay necessary medical intervention. It’s important to seek immediate medical attention to assess the situation and take appropriate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypoglycemia, or low blood sugar, is a condition that can occur in newborns, especially those born to mothers with gestational diabetes. However, there is no information in the question indicating that the mother had gestational diabetes. Therefore, while hypoglycemia is a possible complication for newborns, it is not the most likely complication in this case based on the information provided.
Choice B rationale
Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can occur when a pregnant woman takes drugs such as heroin, codeine, oxycodone (Oxycontin), methadone, or buprenorphine. These and other substances pass through the placenta that connects the baby to its mother in the womb and can cause the baby to become dependent on the drug. In this case, the mother’s urine toxicology screen was positive for cocaine and marijuana, both of which are illicit drugs. This puts the newborn at risk for developing NAS2.
Choice C rationale
Respiratory distress syndrome (RDS) is a breathing disorder that affects newborns. RDS is more common in premature babies because their lungs aren’t fully developed. However, the newborn in the question was born at 38 weeks gestation, which is considered full term. Therefore, while RDS is a possible complication for newborns, it is not the most likely complication in this case based on the information provided.
Choice D rationale
Neonatal jaundice is a condition that can occur in newborns due to high levels of bilirubin, a yellow pigment produced during normal breakdown of red blood cells. In older babies and adults, the liver processes bilirubin, which then passes from the body through the stool and urine. However, a newborn’s still-developing liver may not be mature enough to remove this bilirubin. While neonatal jaundice is a common condition, there is no information in the question indicating that the newborn is at risk for developing this complication.
Correct Answer is C
Explanation
Choice A rationale
The client who has an indwelling urinary catheter to gravity drainage is not at risk for hypokalemia. The kidneys regulate the balance of potassium by removing excess potassium into the urine. The use of a urinary catheter would not affect this process.
Choice B rationale
The client who has a chest tube to water seal is not at risk for hypokalemia. Chest tubes are used to treat conditions that can cause the lung to collapse, such as pneumothorax, hemothorax, or pleural effusion. They do not affect the body’s potassium levels.
Choice C rationale
The client who has a nasogastric (NG) tube to suction is at risk for hypokalemia. Hypokalemia, or low potassium levels, can occur with loss of gastric fluids because these fluids contain potassium. With an NG tube to suction, these fluids are being removed from the body, which can lead to a decrease in potassium levels.
Choice D rationale
The client who has a tracheostomy tube attached to humidified oxygen is not at risk for hypokalemia. A tracheostomy tube allows air to enter the lungs. It does not affect the body’s potassium levels.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.