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 A
Explanation
Amniotic fluid index of 4 cm indicates oligohydramnios, which means too little amniotic fluid.This can cause fetal growth restriction, cord compression, and congenital anomalies.
Choice B is wrong because amniotic fluid index of 8 cm is within the normal range of 5 to 25 cm.
Choice C is wrong because amniotic fluid index of 12 cm is also within the normal range and close to the median value of 14 cm.
Choice D is wrong because amniotic fluid index of 16 cm is also within the normal range and does not indicate oligohydramnios.
Correct Answer is A
Explanation
“This medication can cause premature closure of your baby’s ductus arteriosus.”
Indomethacin is a NSAID that can prevent the synthesis of prostaglandins, which are involved in preterm contractions.However, it can also cause constrictive effects on the fetal ductus arteriosus, which can lead to cardiac complications and oligohydramnios.The dosage and duration of indomethacin treatment should be carefully monitored.
Choice B is wrong because indomethacin does not increase the risk of postpartum hemorrhage.In fact, it may reduce the risk of bleeding by inhibiting platelet aggregation.
Choice C is wrong because indomethacin does not cause jaundice in the baby.
Jaundice is caused by high levels of bilirubin in the blood, which can be due to various factors such as blood group incompatibility, infection, or liver problems.
Choice D is wrong because indomethacin does not increase blood pressure during labor.It may actually lower blood pressure by dilating blood vessels.
Normal ranges for indomethacin dosage are 25 to 50 mg orally every 6 hours or 100 mg rectally every 12 hours for up to 48 hours.
Normal ranges for fetal ductus arteriosus diameter are 1.5 to 4 mm before 28 weeks of gestation and 1 to 3 mm after 28 weeks of gestation.
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