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
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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Related Questions
Correct Answer is B
Explanation
Blood pressure of 150/90 mmHg.This is because terbutaline can causeelevated blood pressureas a side effect.
The nurse should report this finding to the provider as it may indicate hypertension or a hypertensive crisis.
Choice A is wrong because a heart rate of 110/min is not abnormal for a person who has received terbutaline.Terbutaline can causefast or pounding heartbeatsas a common side effect.
Choice C is wrong because a blood glucose of 90 mg/dL is within the normal range of 70-130 mg/dL before meals.Terbutaline can causetransient hyperglycemia(high blood sugar) as a serious side effect, but this is not the case here.
Choice D is wrong because a temperature of 37°C (98.6°F) is normal for a human being.Terbutaline does not cause fever or hypothermia as a side effect.
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.
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