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
Tarry stools are not a typical manifestation of cirrhosis. They are more commonly associated with gastrointestinal bleeding.
Choice B rationale
Spider angiomas are a common manifestation of cirrhosis. They are small, dilated blood vessels with a bright red center point and radiating branches, and they are often found on the face, neck, and chest.
Choice C rationale
Moist skin is not a typical manifestation of cirrhosis. Cirrhosis can cause various skin changes, but they typically include jaundice, pruritus, and palmar erythema.
Choice D rationale
Blood in the urine is not a typical manifestation of cirrhosis. It is more commonly associated with urinary tract infections, kidney stones, or bladder disorders.
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.
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