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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Cervix is shortened and thinned.This indicates cervical effacement, which is the thinning and softening of the cervix in preparation for childbirth.Cervical effacement is measured in percentages, from 0% (no effacement) to 100% (fully effaced).
Choice A is wrong because cervix is soft and pliable does not necessarily mean it is effaced.The cervix can soften before it thins and shortens.
Choice C is wrong because cervix is dilated and open indicates cervical dilation, which is the opening of the cervix.Cervical dilation is measured in centimeters, from 0 cm (closed) to 10 cm (fully dilated).
Cervical dilation and effacement are related, but not the same.
Choice D is wrong because cervix is posterior and high indicates the position of the cervix in relation to the vagina.The cervix can move from posterior (back) to anterior (front) and from high to low as labor progresses.
The position of the cervix does not indicate effacement.
Correct Answer is A
Explanation
Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that helps close the ductus arteriosus, a blood vessel connecting two arteries of the heart (aorta and pulmonary artery) in fetus.This drug is effective only among premature babies.
Choice B.Prostaglandin E1 is wrong because it is used to keep the ductus arteriosus open in some congenital heart defects that require surgery.
Choice C.Furosemide is wrong because it is a diuretic that reduces fluid retention and blood pressure, but does not affect the ductus arteriosus.
Choice D.Digoxin is wrong because it is a cardiac glycoside that strengthens the heart muscle contractions and regulates the heart rhythm, but does not affect the ductus arteriosus.
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