A client who is primigravida at term comes to the prenatal clinic and tells the practical nurse (PN) that she is having contractions every 5 minutes. The PN monitors the client for one hour using an external fetal monitor, and determines that the client's contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. Which action should the PN take?
Tell the client to go directly to the hospital for admission to labor and delivery for active labor.
Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour.
Direct the client to check into the hospital within the next hour for evaluation of possible urinary tract infection.
Send the client home and tell her to drink at least 1,000 mL of fluid each day to flush her bladder.
The Correct Answer is B
A. The client's contractions are not regular or intense enough to indicate active labor, so immediate hospital admission is not necessary.
B. Instructing the client to call the clinic when her contractions occur 5 minutes apart for one hour ensures she is monitored for the progression of labor and can seek timely assistance when labor becomes more active.
C. While a urinary tract infection could cause contractions, the primary focus should be on monitoring labor progression, not diagnosing a UTI at this stage.
D. Hydration is important, but the primary instruction should relate to monitoring contraction patterns for signs of active labor.
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Related Questions
Correct Answer is A
Explanation
A. Diaper changes help assess the baby’s urinary output and general hydration status. If the newborn is producing urine, it suggests proper kidney function and adequate fluid intake, which are essential considerations before transferring the baby to the nursery.
B. While this promotes bonding and allows the mother to assess her baby visually, it does not directly address health indicators such as feeding or elimination, which are critical for ensuring the newborn’s well-being.
C. Noting if the baby is sleeping is a routine observation but does not address the importance of maternal bonding.
D. Whether the family has seen the baby is less critical than ensuring the mother has had early bonding opportunities.
Correct Answer is D
Explanation
A. Administering half of the missed dose is not generally recommended because it could lead to inconsistent drug levels and potential for breakthrough seizures. The standard practice is to follow the dosing schedule unless otherwise instructed by the healthcare provider.
B. Giving the missed dose with the next scheduled dose may lead to double dosing and could increase the risk of side effects or toxicity. The missed dose should be addressed as soon as possible but not in combination with the next dose.
C. Withholding the missed dose unless seizure activity occurs could put the client at risk for seizures. Anticonvulsants should be administered as per the prescribed schedule to maintain therapeutic drug levels and prevent seizures.
D. Administering the missed dose as soon as possible is the correct approach, following standard guidelines for missed medications. The missed dose should be given promptly unless it is close to the time of the next dose, in which case the next dose should be given as scheduled.
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