A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?

Estimated amount of fluid.

Color and consistency of fluid.

Time the membranes ruptured

Any odor noted when membranes ruptured

Answer and Explanation

The Correct Answer is C

A. Estimated amount of fluid:
Knowing the estimated amount of amniotic fluid can provide some information, but it may not be as crucial as other factors in this situation. The primary concern is often related to the color and odor of the amniotic fluid to assess for potential issues.

B. Color and consistency of fluid:
This is a crucial piece of information. The color and consistency of amniotic fluid can provide important clues about fetal well-being and the presence of meconium, which may indicate fetal distress.

C. Time the membranes ruptured:
Knowing the time when the membranes ruptured is essential for assessing the duration of time since the rupture. This information helps in determining the risk of infection, which is a concern after prolonged rupture of membranes.

D. Any odor noted when membranes ruptured:
This is also a critical piece of information. An unpleasant odor, especially if it is foul-smelling, could be indicative of infection. Infection risk increases with prolonged rupture of membranes.

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Correct Answer is C

Explanation

A. Hemoglobin A1C: Hemoglobin A1C is a test that reflects the average blood sugar levels over the past two to three months. It is not typically used for diagnosing gestational diabetes.

B. Postprandial blood glucose test: This test measures blood sugar levels after meals. While it can provide information about how the body processes glucose after eating, it's not the primary test for diagnosing gestational diabetes.

C. Fasting blood glucose: This test measures blood sugar levels after a period of fasting. It is a standard test used to diagnose gestational diabetes.

D. Oral glucose tolerance test (OGTT): This test involves fasting overnight and then drinking a glucose solution. Blood sugar levels are tested at intervals afterward. The OGTT is a common diagnostic test for gestational diabetes.

A. Discuss options for intrauterine surgical correction of congenital defects. B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated. C. Reassure the client that the AFP results are likely to be a false reading. D. Explain that a sonogram should be scheduled for definitive results

Correct Answer is D

Explanation

A. Discuss options for intrauterine surgical correction of congenital defects:At this point, the AFP result is only an indicator, not a diagnosis. The client has not undergone sufficient diagnostic evaluation (such as ultrasound) to confirm any congenital defect that would warrant intrauterine surgery. Treatment options can only be discussed once a definitive diagnosis has been made.

B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated:While a repeat AFP test could be done in some cases to rule out lab error or confirm the result, this is not typically the immediate next step. An ultrasound provides more definitive and comprehensive information than simply repeating the AFP test.

C. Reassure the client that the AFP results are likely to be a false reading:Providing false reassurance may lead to misunderstandings. While false positives can happen, it's crucial to follow up with further assessments to ensure the accuracy of the results.

D. Explain that a sonogram should be scheduled for definitive results:An elevated AFP level is a screening test, not a definitive diagnosis. A sonogram (ultrasound) is the next step to obtain more detailed information about the fetus. Ultrasound can help assess for neural tube defects, confirm gestational age, and check for other anomalies that could explain the elevated AFP levels. This provides the most accurate and non-invasive method for evaluating potential fetal abnormalities.

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A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is 24-weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

Correct Answer is C

Explanation

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Correct Answer is D

Explanation

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A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

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