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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Amniotic fluid index of 4 cm indicates oligohydramnios, which means too little amniotic fluid.This can cause fetal growth restriction, cord compression, and congenital anomalies.
Choice B is wrong because amniotic fluid index of 8 cm is within the normal range of 5 to 25 cm.
Choice C is wrong because amniotic fluid index of 12 cm is also within the normal range and close to the median value of 14 cm.
Choice D is wrong because amniotic fluid index of 16 cm is also within the normal range and does not indicate oligohydramnios.
Correct Answer is A
Explanation
Ultrasound.
An ultrasound can help determine the gestational age, fetal growth, placental location, and amniotic fluid volume of the fetus.
These factors can affect the risk of pre-term labor and delivery.
An ultrasound can also detect cervical changes that may indicate pre-term labor.
Choice B is wrong because a blood count is not specific for pre-term labor.
It may be done to check for anemia, infection, or other conditions that may affect the pregnancy, but it does not directly assess the risk of pre-term labor.
Choice C is wrong because a urine culture is not specific for pre-term labor.
It may be done to check for urinary tract infection, which can cause pre-term labor, but it does not directly assess the risk of pre-term labor.
Choice D is wrong because an amniocentesis is not usually done for pre-term labor.
It may be done to check for fetal lung maturity, chromosomal abnormalities, or infections, but it is an invasive procedure that carries some risks and complications.
It does not directly assess the risk of pre-term labor.
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