A nurse is admitting a client who is in pre-term labor at 34 weeks of gestation and has ruptured membranes and oligohydramnios.

Which of the following actions should the nurse take first?

Administer IV fluids

Obtain a urine specimen

Assess fetal heart rate

Insert an indwelling urinary catheter

Answer and Explanation

The Correct Answer is C

This is because assessing fetal heart rate is the most important action to take first when a client has prelabor rupture of membranes (PROM) at 34 weeks of gestation and oligohydramnios. Fetal heart rate can indicate fetal well-being, distress, or infection. Oligohydramnios can increase the risk of umbilical cord compression and fetal hypoxia.

Choice A is wrong because administering IV fluids is not the first priority in this situation. IV fluids may be given to prevent dehydration, enhance uterine blood flow, or augment labor, but they are not as urgent as assessing fetal heart rate.

Choice B is wrong because obtaining a urine specimen is not the first priority in this situation. A urine specimen may be obtained to check for infection, proteinuria, or glucose levels, but they are not as urgent as assessing fetal heart rate.

Choice D is wrong because inserting an indwelling urinary catheter is not the first priority in this situation. An indwelling urinary catheter may be inserted to monitor fluid balance, prevent bladder distension, or reduce the risk of infection, but they are not as urgent as assessing fetal heart rate.

Normal ranges for fetal heart rate are 110 to 160 beats per minute. Oligohydramnios is defined as an amniotic fluid index of less than 5 cm.

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Correct Answer is A

Explanation

Nitrazine paper test.

This test involves putting a drop of fluid obtained from the vagina onto paper strips containing nitrazine dye.

The strips change color depending on the pH of the fluid.The strips will turn blue if the pH is greater than 6.0, which indicates the presence of amniotic fluid.This test can help confirm rupture of membranes (ROM) in pregnancy, especially when preterm labor is suspected.

Choice B. Ferning test.This test involves examining a sample of vaginal fluid under a microscope and looking for a fern-like pattern that is formed by dried amniotic fluid crystals.This test can also help confirm ROM, but it is less reliable than the nitrazine test because other substances such as cervical mucus, semen, or blood can also cause ferning.

Choice C. Amniotic fluid index.This test involves measuring the amount of amniotic fluid in the uterus using ultrasound.This test can help assess the fetal well-being and detect conditions such as oligohydramnios (low amniotic fluid) or polyhydramnios (high amniotic fluid).This test cannot confirm ROM by itself, but it can be used in combination with other tests to evaluate the status of the pregnancy.

Choice D. Biophysical profile.This test involves using ultrasound and a fetal monitor to assess the fetal heart rate, breathing, movement, muscle tone, and amniotic fluid volume.

A. Indomethacin B. Prostaglandin E1 C. Furosemide D. Digoxin

Correct Answer is A

Explanation

Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that helps close the ductus arteriosus, a blood vessel connecting two arteries of the heart (aorta and pulmonary artery) in fetus.This drug is effective only among premature babies.

Choice B.Prostaglandin E1 is wrong because it is used to keep the ductus arteriosus open in some congenital heart defects that require surgery.

Choice C.Furosemide is wrong because it is a diuretic that reduces fluid retention and blood pressure, but does not affect the ductus arteriosus.

Choice D.Digoxin is wrong because it is a cardiac glycoside that strengthens the heart muscle contractions and regulates the heart rhythm, but does not affect the ductus arteriosus.

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A nurse is admitting a client who is in pre-term labor at 34 weeks of gestation and has ruptured membranes and oligohydramnios. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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A nurse is admitting a client who is in pre-term labor at 34 weeks of gestation and has ruptured membranes and oligohydramnios.

Which of the following actions should the nurse take first?