A client in pre-term labor is being discharged from the hospital.
What should the nurse include in the client's discharge plan?
Referral to community services for support
Encouragement to smoke in moderation
Instructions for heavy lifting and strenuous exercise
Recommendation to avoid kangaroo care
The Correct Answer is A
A. Referral to community services for support.
A client in preterm labor who is being discharged from the hospital needs to have a discharge plan that includes education, follow-up care, and support services. A referral to community services for support can help the client cope with the stress and anxiety of preterm labor, access resources such as home health care or social workers, and prevent complications or recurrence of preterm labor.
B. Encouragement to smoke in moderation is wrong because smoking is harmful for both the mother and the baby.
Smoking can increase the risk of preterm labor, low birth weight, placental abruption, and sudden infant death syndrome (SIDS). Smoking should be avoided completely during pregnancy and after delivery.
C. Instructions for heavy lifting and strenuous exercise is wrong because these activities can trigger uterine contractions and increase the risk of preterm labor.
A client in preterm labor should rest as much as possible and avoid physical exertion. The client should also avoid sexual intercourse, which can stimulate the cervix and cause bleeding or infection.
D. Recommendation to avoid kangaroo care is wrong because kangaroo care is a method of holding a newborn skin-to-skin with the mother or father.
Kangaroo care can have many benefits for preterm babies, such as improving temperature regulation, breathing, heart rate, feeding, bonding, and growth. Kangaroo care can also reduce stress and pain for both the baby and the parent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Instruct the client to empty her bladder.This is because a full bladder can interfere with the insertion of the needle and increase the risk of injury to the bladder or the uterus.Emptying the bladder also reduces discomfort during the procedure.
Choice A is wrong because administering tocolytic medication to stop contractions is not necessary before amniocentesis.Tocolytic medication can have side effects and should only be used when there is a clear indication of preterm labor.
Choice C is wrong because obtaining informed consent from the client is not a nursing action, but a medical one.The nurse can assist in providing information and answering questions, but the final consent should be obtained by the doctor who will perform the procedure.
Choice D is wrong because monitoring fetal heart rate and activity is not a specific action before amniocentesis, but a routine part of prenatal care.Fetal heart rate and activity can be affected by many factors, such as maternal position, fetal sleep cycle, or maternal blood sugar level.
Monitoring them before amniocentesis does not provide any useful information for the procedure.
Correct Answer is A
Explanation
Assess fetal heart rate and activity.
The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.
Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.
Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.
Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.
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