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 C

Explanation

The therapeutic effect of magnesium sulfate is to inhibit uterine contractions and prevent or delay preterm labor.

By assessing uterine activity, the nurse can evaluate if the medication is working or not.

Choice A is wrong because measuring urine output is not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for toxicity and renal function.

Choice B is wrong because checking deep tendon reflexes is also not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for neuromuscular effects and toxicity.

Choice D is wrong because monitoring blood pressure is not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for cardiovascular effects and toxicity.

A. Referral to community services for support B. Encouragement to smoke in moderation C. Instructions for heavy lifting and strenuous exercise D. Recommendation to avoid kangaroo care

Correct Answer is A

Explanation

A. Referral to community services for support.

A client in preterm labor who is being discharged from the hospital needs to have a discharge plan that includes education, follow-up care, and support services.A referral to community services for support can help the client cope with the stress and anxiety of preterm labor, access resources such as home health care or social workers, and prevent complications or recurrence of preterm labor.

B. Encouragement to smoke in moderation is wrong because smoking is harmful for both the mother and the baby.

Smoking can increase the risk of preterm labor, low birth weight, placental abruption, and sudden infant death syndrome (SIDS).Smoking should be avoided completely during pregnancy and after delivery.

C. Instructions for heavy lifting and strenuous exercise is wrong because these activities can trigger uterine contractions and increase the risk of preterm labor.

A client in preterm labor should rest as much as possible and avoid physical exertion.The client should also avoid sexual intercourse, which can stimulate the cervix and cause bleeding or infection.

D. Recommendation to avoid kangaroo care is wrong because kangaroo care is a method of holding a newborn skin-to-skin with the mother or father.

Kangaroo care can have many benefits for preterm babies, such as improving temperature regulation, breathing, heart rate, feeding, bonding, and growth.Kangaroo care can also reduce stress and pain for both the baby and the parent.

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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 nurse is caring for a client who is receiving magnesium sulfate for pre-term labor. Which of the following assessments should the nurse perform to evaluate the therapeutic effect of the medication?

Correct Answer is C

Explanation

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 providing education to a client and her partner about pre-term labor. Which intervention should the nurse include in the teaching plan to address possible outcomes and complications?

A nurse is monitoring a client who is at 29 weeks of gestation and has pre-term labor. The client is receiving magnesium sulfate IV infusion. Which of the following are expected adverse effects of this medication? (Select all that apply)

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 client at 30 weeks of gestation is experiencing pre-term labor. Which intervention should the nurse anticipate to suppress uterine contractions?

A nurse is planning care for a pre-term infant who is in an incubator. Which of the following interventions should the nurse include to promote bonding between the infant and the parents?

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 evaluating the understanding of a client who is at risk for pre-term labor and has been instructed to perform daily home uterine activity monitoring (HUAM). Which of the following statements by the client indicates a need for further teaching?

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?