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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

All of the above.

Respiratory distress syndrome (RDS) is a condition that affects preterm newborns who have immature lungs and lack sufficient surfactant.

Surfactant is a substance that helps keep the alveoli open and prevents them from collapsing.

Without enough surfactant, the newborn has difficulty breathing and may develop hypoxia and acidosis.

Choice A is wrong because tachypnea and grunting are signs of respiratory distress, but they are not specific to RDS.

They can also be caused by other conditions such as transient tachypnea of the newborn, pneumonia, or congenital heart defects.

Choice B is wrong because bradycardia and cyanosis are also signs of respiratory distress, but they are not specific to RDS.

They can also be caused by other conditions such as hypothermia, hypoglycemia, or sepsis.

Choice C is wrong because apnea and nasal flaring are also signs of respiratory distress, but they are not specific to RDS.

They can also be caused by other conditions such as intracranial ...

A. Referral to community services for support B. Encouragement to smoke in moderation C. Instructions for heavy lifting and strenuous exercise D. Recommendation to avoid kangaroo care

Correct Answer is A

Explanation

A. Referral to community services for support.

Referral to community services for support is an important part of the discharge plan for a client in preterm labor.Community services can provide education, counseling, home visits, and other resources to help the client cope with preterm labor and prevent complications.

B. Encouragement to smoke in moderation.Statement is wrong because smoking is harmful for the unborn baby and can increase the risk of preterm labor.Smoking should be avoided completely during pregnancy and the client should be advised to quit or seek help to quit.

C. Instructions for heavy lifting and strenuous exercise.Statement is wrong because heavy lifting and strenuous exercise can trigger contractions and worsen preterm labor.The client should be instructed to rest as much as possible and avoid activities that may cause uterine irritation or bleeding.

D. Recommendation to avoid kangaroo care.Statement is wrong because kangaroo care, or skin-to-skin contact with the baby, is beneficial for both the mother and the baby after birth.Kangaroo care can help regulate the baby’s temperature, heart rate, breathing, and blood sugar levels, as well as promote bonding, breastfeeding, and infection prevention.The client should be encouraged to practice kangaroo care as soon as possible after delivery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 assessing a pre-term newborn who was born at 28 weeks of gestation. Which of the following findings indicates a possible diagnosis of respiratory distress syndrome (RDS)?

Correct Answer is D

Explanation

A client in pre-term labor is being discharged from the hospital. What should the nurse include in the client's discharge plan?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who delivered a pre-term newborn at 34 weeks of gestation. Which of the following instructions should the nurse include in the teaching?

A nurse is providing education to a client and her partner about pre-term labor. Which intervention should the nurse include in the teaching plan to address possible outcomes and complications?

A nurse is reviewing the laboratory results of a client who is at 29 weeks of gestation and has pre-term labor. Which of the following results indicates an infection that can trigger pre-term labor?

A nurse is teaching a client who is pregnant about the risk factors for pre-term labor. Which of the following statements by the client indicates a need for further teaching?

A client at 28 weeks of gestation presents with bleeding from the vagina. Which assessment finding should the nurse prioritize?

A nurse is preparing to perform an amniocentesis on a client who is at 27 weeks of gestation and has pre-term labor. Which of the following actions should the nurse take before the procedure?

A nurse is caring for a client who is receiving magnesium sulfate for pre-term labor. Which of the following assessments should the nurse perform to evaluate the therapeutic effect of the medication?

A nurse is teaching a client who is at 25 weeks of gestation and has pre-term labor about the purpose and side effects of magnesium sulfate therapy. Which of the following statements by the client indicates an understanding of the teaching?

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?