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.

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

“I will call my doctor if I have more than four contractions in an hour.” This statement indicates that the client understands the signs of preterm labor and when to seek medical attention.Preterm labor is defined as having regular contractions and cervical changes before 37 weeks of gestation.More than four contractions in an hour may indicate that preterm labor is occurring and requires prompt evaluation.

Choice A is wrong because drinking at least eight glasses of water every day is not a specific instruction for preventing preterm labor.However, dehydration can trigger contractions and should be avoided.

Choice B is wrong because lying on the back with a pillow under the knees can reduce blood flow to the uterus and the baby.This position can also increase the risk of blood clots in the legs.A better position is lying on the left side, which improves circulation and reduces pressure on the cervix.

Choice C is wrong because avoiding sexual intercourse until reaching term is not necessary for most women with a history of preterm labor.Sexual activity does not cause preterm labor or premature rupture of membranes (PROM).However, some women may be advised to abstain from sex if they have certain conditions, such as placenta previa or a short cervix.

A. Assess the client’s vital signs B. Perform a sterile vaginal exam C. Administer tocolytic medication D. Monitor the fetal heart rate

Correct Answer is A

Explanation

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.

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 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 providing discharge instructions to a client who had pre-term labor at 32 weeks of gestation and was prescribed bed rest at home. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

A nurse is providing education to a client who had pre-term labor and was prescribed indomethacin. Which of the following information should the nurse include in the teaching?

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 caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure. Which intervention should the nurse implement first?

A nurse is administering betamethasone to a client who is in pre-term labor at 28 weeks of gestation. The nurse should explain that the purpose of this medication is to:

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?

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 nurse is monitoring a client who is receiving terbutaline for pre-term labor. Which of the following findings should the nurse report to the provider as a potential adverse effect of the medication?

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?