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.”.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Administering the insulin 30 minutes after breakfast is not recommended. Regular insulin should be administered before meals.

Choice B rationale

Administering the insulin at 0700 is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.

Choice C rationale

Administering the insulin at 0730 is recommended if breakfast is at 0800. Regular insulin should be administered 30 to 45 minutes before a meal. This is the correct answer.

Choice D rationale

Administering the insulin when the breakfast tray arrives is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.

A. Ask the client if she has considered harming her newborn. B. Anticipate a prescription by the provider for an antidepressant. C. Assist the family to identify prior use of positive coping skills in family crises. D. Reinforce postpartum and newborn care discharge teaching.

Correct Answer is A

Explanation

Choice A rationale

If a client reports feeling “down” and sad, having no energy, and wanting to cry, these could be signs of postpartum depression. It’s crucial to assess whether the client has considered harming her newborn, as this could indicate a severe form of postpartum depression that requires immediate intervention.

Choice B rationale

While anticipating a prescription for an antidepressant might be part of the treatment plan for postpartum depression, it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

Choice C rationale

Assisting the family to identify prior use of positive coping skills in family crises could be helpful, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

Choice D rationale

Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

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A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.What should be the appropriate response by the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with diabetes and plans to administer regular insulin subcutaneously before breakfast at 0800.After checking the patient’s morning glucose level, what action should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.
What should be the appropriate response by the nurse?