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 A

Explanation

A. Referral to community services for support.

Referral to community services for support is an important part of the discharge plan for a client in preterm labor.Community services can provide education, counseling, home visits, and other resources to help the client cope with preterm labor and prevent complications.

B. Encouragement to smoke in moderation.Statement is wrong because smoking is harmful for the unborn baby and can increase the risk of preterm labor.Smoking should be avoided completely during pregnancy and the client should be advised to quit or seek help to quit.

C. Instructions for heavy lifting and strenuous exercise.Statement is wrong because heavy lifting and strenuous exercise can trigger contractions and worsen preterm labor.The client should be instructed to rest as much as possible and avoid activities that may cause uterine irritation or bleeding.

D. Recommendation to avoid kangaroo care.Statement is wrong because kangaroo care, or skin-to-skin contact with the baby, is beneficial for both the mother and the baby after birth.Kangaroo care can help regulate the baby’s temperature, heart rate, breathing, and blood sugar levels, as well as promote bonding, breastfeeding, and infection prevention.The client should be encouraged to practice kangaroo care as soon as possible after delivery.

A. Decreased fetal movement B. Increased vaginal discharge C. Pelvic pressure D. All of the above

Correct Answer is D

Explanation

All of the above.The nurse should include all of these signs and symptoms in the teaching as they may indicate pre-term labor.Pre-term labor occurs when regular contractions begin to open the cervix before 37 weeks of pregnancy.

Choice A is wrong because decreased fetal movement is not a normal sign of pre-term labor, but it may indicate fetal distress or other complications.

Choice B is wrong because increased vaginal discharge is not a normal sign of pre-term labor, but it may indicate infection or rupture of membranes.

Choice C is wrong because pelvic pressure is not a normal sign of pre-term labor, but it may indicate cervical dilation or descent of the fetus.

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

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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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?