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

Lying on one’s back with knees bent while using the monitor is not recommended for women at risk of preterm labor, as it can put pressure on the inferior vena cava, a major vein leading back to the heart.This can cause low blood pressure and reduce blood flow to the uterus and the baby.A better position is to lie on one’s side with a pillow at the back for support.

Choice A is correct because emptying the bladder before applying the monitor can reduce interference from urine contractions and make the readings more accurate.

Choice C is correct because pressing the event marker every time one feels a contraction can help record the frequency and duration of uterine activity.

Choice D is correct because using the monitor for at least 1 hour twice a day can provide sufficient data on uterine contractions and help detect early signs of preterm labor.

A. The client reports decreased uterine contractions B. The client’s blood pressure decreases to within normal limits C. The client’s deep tendon reflexes are 2+ D. The client’s urine output increases to more than 30 mL/hr

Correct Answer is A

Explanation

Magnesium sulfate is a tocolytic drug that inhibits uterine activity and relaxes smooth muscles.The goal of magnesium sulfate therapy for a client who is in pre-term labor is to stop or reduce the frequency and intensity of contractions.

Choice B is wrong because the client’s blood pressure decreases to within normal limits.

Magnesium sulfate is not an antihypertensive drug and does not lower blood pressure.It is used to prevent seizures in clients with preeclampsia or eclampsia.

Choice C is wrong because the client’s deep tendon reflexes are 2+.

This is a normal finding and does not indicate the effectiveness of magnesium sulfate therapy.A decrease or loss of deep tendon reflexes may indicate magnesium toxicity, which is a serious complication that requires immediate intervention.

Choice D is wrong because the client’s urine output increases to more than 30 mL/hr.

This is also a normal finding and does not indicate the effectiveness of magnesium sulfate therapy.A decrease in urine output may indicate renal impairment or magnesium toxicity, which are both adverse effects of the drug.

The normal range for serum magnesium level is 1.5 to 2.5 mEq/L or 1.8 to 3 mg/dL.The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL.

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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

A nurse is evaluating the understanding of a client who is at risk for pre-term labor and has been instructed to perform daily home uterine activity monitoring (HUAM). Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client who is in pre-term labor. Which of the following findings indicates that the therapy is successful?

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?