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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that can cause renal impairment and elevated serum creatinine levels in both the mother and the fetus.This can lead to oligohydramnios, reduced fetal urine output, and fetal renal failure.
Therefore, the nurse should monitor the serum creatinine levels of the client and the fetus as a potential complication of indomethacin.
Choice A is wrong because indomethacin does not affect the platelet count.It may increase the risk of bleeding due to its antiplatelet effect, but it does not cause thrombocytopenia.
Choice C is wrong because indomethacin does not cause anemia or decrease the hematocrit.It may cause gastrointestinal bleeding or ulceration, which could lead to anemia, but this is not a common or direct effect of the medication.
Choice D is wrong because indomethacin does not cause hyperkalemia or increase the serum potassium levels.It may cause hyponatremia due to its effect on renal sodium excretion, but it does not affect potassium balance.
Correct Answer is C
Explanation
White blood cell count 25,000/mm3.
This indicates a potential complication of necrotizing enterocolitis (NEC), which is the death of intestinal tissue in premature or sick newborns.A high white blood cell count can be a sign of infection or inflammation in the bowel, which are common features of NEC.
Choice A is wrong because hematocrit 45% is within the normal range for newborns.
Hematocrit measures the percentage of red blood cells in the blood.
A low hematocrit can indicate blood loss or anemia, which can be complications of NEC, but a normal hematocrit does not rule out NEC.
Choice B is wrong because platelets 150,000/mm3 is also within the normal range for newborns.
Platelets are cells that help the blood clot.A low platelet count can indicate a consumption coagulopathy, which is a bleeding disorder that can occur in severe cases of NEC.
However, a normal platelet count does not exclude NEC.
Choice D is wrong because blood glucose 80 mg/dL is also within the normal range for newborns.
Blood glucose measures the amount of sugar in the blood.
A low blood glucose can indicate hypoglycemia, which can be caused by sepsis or other conditions that mimic NEC, but a normal blood glucose does not eliminate NEC.
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