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 D
Explanation
Choice A rationale
Pyorrhea, also known as periodontitis, is a severe gum infection that damages gums and can destroy the jawbone. It is not related to bleeding between menstrual periods.
Choice B rationale
Dysmenorrhea refers to painful periods, not bleeding between periods.
Choice C rationale
Menorrhagia is a term used to describe heavy or prolonged menstrual bleeding, not bleeding between periods.
Choice D rationale
Metrorrhagia is the term used to describe bleeding between menstrual periods. When documenting this finding, it’s helpful to keep a record of the menstrual cycle, noting when periods begin and end, the heaviness and duration of the flow, and when and how much bleeding occurs between periods.
Correct Answer is B
Explanation
Choice A rationale
Quickening is the sensation of fetal movement by the pregnant woman. It usually occurs between 16 and 20 weeks of gestation.
Choice B rationale
Hegar’s sign is a probable sign of pregnancy that is characterized by the compressibility and softening of the cervical isthmus, which is the portion of the cervix between the uterus and the vaginal portion of the cervix. This sign typically presents between the fourth and sixth week of pregnancy. Therefore, if the nurse identifies a probable sign indicating the softening of the lower uterine segment, it is likely that the nurse has observed Hegar’s sign.
Choice C rationale
Braxton Hicks contractions are intermittent uterine contractions that occur during pregnancy. They are not a sign of labor and do not lead to cervical dilation or effacement. Therefore, they would not indicate the softening of the lower uterine segment.
Choice D rationale
Ballottement is a technique of palpating a floating structure by bouncing it and feeling it rebound. In the context of pregnancy, it refers to the movement of the fetus when the uterus is tapped during a pelvic examination. This does not indicate the softening of the lower uterine segment.
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