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
Hyperglycemia, or high blood sugar, is a condition that is most commonly seen in individuals with diabetes. Symptoms can include frequent urination, increased thirst, and increased hunger. If left untreated, it can lead to serious complications such as diabetic ketoacidosis.
Choice B rationale
Anemia is a condition characterized by a decrease in the total amount of red blood cells or hemoglobin in the blood, or a lowered ability of the blood to carry oxygen. Symptoms can include fatigue, weakness, pale or yellowish skin, irregular heartbeats, shortness of breath, dizziness or lightheadedness, and chest pain.
Choice C rationale
Type 1 diabetes mellitus is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs when the body becomes resistant to insulin or doesn’t make enough insulin.
Choice D rationale
Hypertension, or high blood pressure, is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. If the nurse is reviewing the client’s medical records and actions to be taken, it is likely that the client is experiencing hypertension.
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.
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