A nurse is caring for a client who is at 32 weeks of gestation and reports lower abdominal cramping.

Which of the following actions should the nurse take first?

Assess the client’s vital signs

Perform a sterile vaginal exam

Administer tocolytic medication

Monitor the fetal heart rate

Answer and Explanation

The Correct Answer is A

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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Correct Answer is A

Explanation

Leukocoria (white pupils) is a symptom of retinopathy of prematurity (ROP), an eye disease that can happen in premature babies.ROP happens when abnormal blood vessels grow on the retina, the light-sensitive layer of tissue in the back of the eye.

Choice B is wrong because strabismus (crossed eyes) is not a symptom of ROP, but a possible complication that can occur later in life.

Choice C is wrong because nystagmus (involuntary eye movements) is not a symptom of ROP, but another possible complication that can occur later in life.

Choice D is wrong because it includes choices B and C, which are incorrect.

Normal ranges for gestational age and birth weight are 38 to 42 weeks and 5.5 to 10 pounds, respectively.Babies born before 31 weeks or weighing less than 3 pounds are at risk for ROP.

A. Nitrazine paper test B. Ferning test C. Amniotic fluid index D. Biophysical profile

Correct Answer is A

Explanation

Nitrazine paper test.

This test involves putting a drop of fluid obtained from the vagina onto paper strips containing nitrazine dye.

The strips change color depending on the pH of the fluid.The strips will turn blue if the pH is greater than 6.0, which indicates the presence of amniotic fluid.This test can help confirm rupture of membranes (ROM) in pregnancy, especially when preterm labor is suspected.

Choice B. Ferning test.This test involves examining a sample of vaginal fluid under a microscope and looking for a fern-like pattern that is formed by dried amniotic fluid crystals.This test can also help confirm ROM, but it is less reliable than the nitrazine test because other substances such as cervical mucus, semen, or blood can also cause ferning.

Choice C. Amniotic fluid index.This test involves measuring the amount of amniotic fluid in the uterus using ultrasound.This test can help assess the fetal well-being and detect conditions such as oligohydramnios (low amniotic fluid) or polyhydramnios (high amniotic fluid).This test cannot confirm ROM by itself, but it can be used in combination with other tests to evaluate the status of the pregnancy.

Choice D. Biophysical profile.This test involves using ultrasound and a fetal monitor to assess the fetal heart rate, breathing, movement, muscle tone, and amniotic fluid volume.

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A nurse is caring for a client who is at 32 weeks of gestation and reports lower abdominal cramping. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a pre-term newborn who has retinopathy of prematurity (ROP). Which of the following manifestations should the nurse expect to observe?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who is at 32 weeks of gestation and reports lower abdominal cramping.

Which of the following actions should the nurse take first?