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 A
Explanation
Choice A rationale
Asking the partner to talk about his difficulties in caring for the client is the nurse’s priority. This intervention allows the nurse to assess the partner’s emotional state and provide appropriate support and resources.
Choice B rationale
Recommending that the partner place the client in a long-term care facility may not be the best initial intervention. The decision to place a loved one in a long-term care facility is complex and involves many factors. The nurse should first assess the partner’s needs and concerns before making such a recommendation.
Choice C rationale
Telling the partner to call a family meeting to get help may be a helpful suggestion, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.
Choice D rationale
Suggesting that the partner see a counselor to help him cope with his exhaustion may be a helpful intervention, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.
Correct Answer is B
Explanation
Choice A rationale
Hematuria, or blood in the urine, is not typically a symptom of postpartum endometritis.
Choice B rationale
Pelvic pain is a common symptom of postpartum endometritis. It is often one of the first symptoms to appear, along with lower abdominal pain and uterine tenderness.
Choice C rationale
While a moderate amount of dark red lochia with a bloody odor can be a normal part of the postpartum period, it is not specifically indicative of endometritis.
Choice D rationale
Localized area of breast tenderness is not typically a symptom of postpartum endometritis.
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