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 B

Explanation

Blood pressure of 150/90 mmHg.This is because terbutaline can causeelevated blood pressureas a side effect.

The nurse should report this finding to the provider as it may indicate hypertension or a hypertensive crisis.

Choice A is wrong because a heart rate of 110/min is not abnormal for a person who has received terbutaline.Terbutaline can causefast or pounding heartbeatsas a common side effect.

Choice C is wrong because a blood glucose of 90 mg/dL is within the normal range of 70-130 mg/dL before meals.Terbutaline can causetransient hyperglycemia(high blood sugar) as a serious side effect, but this is not the case here.

Choice D is wrong because a temperature of 37°C (98.6°F) is normal for a human being.Terbutaline does not cause fever or hypothermia as a side effect.

A. Infection on speculum examination B. Bleeding on speculum examination C. Positive fetal fibronectin test (FFN) D. Normal fetal heart rate and activity

Correct Answer is A

Explanation

Infection on speculum examination.

Infection is a major cause of preterm labor and can lead to serious complications for the mother and the fetus.

Infection can be detected by a speculum examination that shows signs of inflammation, such as erythema, edema, discharge, or odor.

Infection can also be confirmed by laboratory tests, such as culture, gram stain, or polymerase chain reaction.Infection should be treated promptly with antibiotics and other supportive measures.

Choice B. Bleeding on speculum examination is wrong because bleeding is not a direct cause of preterm labor, but rather a sign of other conditions that may increase the risk of preterm labor, such as placenta previa, placental abruption, or cervical trauma.Bleeding should be evaluated further to determine the source and severity of the hemorrhage and to manage any complications.

Choice C. Positive fetal fibronectin test (FFN) is wrong because a positive FFN test indicates the presence of fetal fibronectin in the cervical or vaginal secretions, which is a marker of increased risk of preterm labor, but not a definitive marker.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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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?