A nurse is caring for a client who is at 33 weeks of gestation and has pre-term labor.

The client reports a sudden gush of fluid from her vagina.

Which of the following actions should the nurse take first?

Assess fetal heart rate and activity

Perform a nitrazine test on the fluid

Administer oxytocin (Pitocin) IV infusion

Place the client in Trendelenburg position

Answer and Explanation

The Correct Answer is A

Assess fetal heart rate and activity.

The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk for premature rupture of membranes (PROM), which can lead to infection, cord prolapse, and fetal distress. Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.

Choice B is wrong because performing a nitrazine test on the fluid is not the first action. A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.

Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation. Oxytocin is used to induce or augment labor, but it can cause uterine hyperstimulation, fetal distress, and placental abruption if given to a client who has PROM.

Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM. Trendelenburg position can increase the risk of cord prolapse and aspiration in this situation.

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Correct Answer is C

Explanation

This medication will help relax my uterus and stop contractions.

Magnesium sulfate is a tocolytic, a medication used to suppress uterine contractions and delay preterm delivery.The exact mechanism through which magnesium sulfate inhibits contractions is unknown, but researchers believe it likely works by lowering calcium levels in the uterine muscles.

Choice A is wrong because magnesium sulfate is not used to prevent seizures in case of preeclampsia.

Preeclampsia is a condition characterized by high blood pressure and protein in the urine during pregnancy.Magnesium sulfate may be used to treat seizures if they occur with eclampsia, which is a severe complication of preeclampsia.

Choice B is wrong because magnesium sulfate does not help mature the baby’s lungs in case of preterm birth.

Magnesium sulfate may have some neuroprotective effects for the baby, but it does not affect lung development.Steroids are usually given to pregnant women at risk of preterm delivery to help accelerate fetal lung maturation.

Choice D is wrong because magnesium sulfate does not lower blood pressure in case it gets too high.

Magnesium sulfate may have some vasodilatory effects, but it is not used as an antihypertensive agent.Other medications, such as hydralazine or labetalol, are used to treat high blood pressure during pregnancy.

A. Avoid sexual intercourse until term B. Drink at least 3 L of fluids per day C. Report any increase in vaginal discharge to the provider D. Perform pelvic floor exercises daily

Correct Answer is C

Explanation

Report any increase in vaginal discharge to the provider.This is because an increase in vaginal discharge can indicate an infection, which can trigger preterm labor or cause complications for the mother and the baby.

Choice A is wrong because sexual intercourse is not contraindicated for women who have preterm labor that was successfully stopped with tocolytic therapy, unless they have other risk factors such as placenta previa or ruptured membranes.

Choice B is wrong because drinking at least 3 L of fluids per day is not necessary for women who have preterm labor that was successfully stopped with tocolytic therapy, unless they have dehydration or oligohydramnios.

Choice D is wrong because pelvic floor exercises are not recommended for women who have preterm labor that was successfully stopped with tocolytic therapy, as they can increase uterine activity and cause contractions.

Tocolytic therapy is the use of drugs to delay delivery for a short time (up to 48 hours) if a woman begins labor too early in her pregnancy.

The purpose of tocolytic therapy is to allow time for the administration of corticosteroids or other medicine.

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A nurse is caring for a client who is at 33 weeks of gestation and has pre-term labor. The client reports a sudden gush of fluid from her vagina. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is planning discharge teaching for a client who is at 25 weeks of gestation and has pre-term labor that was successfully stopped with tocolytic therapy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reviewing the medical record of a client who is at 34 weeks of gestation and has pre-term labor. Which of the following findings is a risk factor for pre-term labor?

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?

A nurse is preparing to administer betamethasone (Celestone) to a client who is at 31 weeks of gestation and has pre-term labor. What is the purpose of this medication?

A nurse is reviewing the ultrasound report of a client who is at 31 weeks of gestation and has pre-term labor. Which of the following findings indicates oligohydramnios?

A nurse is administering betamethasone to a client who is at risk for pre-term labor at 30 weeks of gestation. Which of the following outcomes should the nurse monitor for in the newborn?

A nurse is teaching a client who is at risk for pre-term labor about the signs and symptoms to report to the provider. Which of the following should the nurse include in the teaching?

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

A nurse is caring for a client who is at 33 weeks of gestation and has pre-term labor.

The client reports a sudden gush of fluid from her vagina.

Which of the following actions should the nurse take first?