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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Pre-term newborns are at risk of apnea of prematurity, which is a pause in breathing for more than 20 seconds or less than 20 seconds with bradycardia or cyanosis.An apnea monitor can detect and alert the parents of any episodes of apnea and help them intervene promptly.
Choice A is wrong because breastfeeding is beneficial for pre-term newborns and can provide them with antibodies, nutrients, and bonding with the mother.Breastfeeding should be encouraged as soon as the newborn is medically stable and able to suck and swallow.
Choice C is wrong because keeping the newborn in a warm environment at all times can lead to overheating, dehydration, and increased metabolic rate.Pre-term newborns have difficulty regulating their body temperature and need to be dressed appropriately for the ambient temperature.They should also be monitored for signs of cold stress or heat stress.
Choice D is wrong because delaying immunizations until the newborn reaches term gestation can expose the newborn to preventable infections that ...
Correct Answer is A
Explanation
Assess the client’s vital signs.
The nurse should first assess the client’s vital signs to determine the severity of the situation and identify any signs of infection, bleeding, or shock.
The nurse should also monitor the fetal heart rate to assess fetal well-being.
Choice B is wrong because a sterile vaginal exam is not indicated for a client who reports lower abdominal cramping and may increase the risk of infection or rupture of membranes.
Choice C is wrong because administering tocolytic medication is not the first action the nurse should take.
Tocolytic medication may be used to inhibit uterine contractions and prolong pregnancy, but only after assessing the client’s and fetus’s condition and obtaining a prescription from the provider.
Choice D is wrong because monitoring the fetal heart rate is not the first action the nurse should take.
Monitoring the fetal heart rate is important to assess fetal well-being, but it does not take priority over assessing the client’s vital signs.
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