A nurse is teaching a client with preterm premature rupture of membranes (PPROM) regarding self-care activities. Which activities should the nurse include in her teaching?

Tampons are safe to use to absorb the leaking amniotic fluid.

Report a temperature less than 37 degrees C.

Do not engage in sexual activity.

Taking frequent tub baths is safe.

Answer and Explanation

The Correct Answer is C

Choice A reason: Tampons are not safe to use to absorb the leaking amniotic fluid, because they can introduce bacteria into the vagina and uterus, and increase the risk of infection and preterm labor. The nurse should instruct the client to use sanitary pads instead, and change them frequently.

Choice B reason: Reporting a temperature less than 37 degrees C is not a necessary activity, because it is a normal finding and does not indicate any complication. The nurse should instruct the client to report a temperature greater than 37.8 degrees C, which can be a sign of infection or chorioamnionitis.

Choice C reason: Not engaging in sexual activity is a recommended activity, because it can help prevent further rupture of membranes, infection, and preterm labor. The nurse should instruct the client to avoid any vaginal or cervical stimulation, such as intercourse, douching, or tampon use.

Choice D reason: Taking frequent tub baths is not a safe activity, because it can expose the vagina and uterus to contaminated water, and increase the risk of infection and preterm labor. The nurse should instruct the client to take showers instead, and avoid submerging the lower body in water.

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Correct Answer is B

Explanation

Choice A reason: Uterine enlargement greater than expected for gestational age is not a typical manifestation of ectopic pregnancy, because the embryo is implanted outside the uterus, usually in the fallopian tube. The uterus may be slightly enlarged due to hormonal changes, but not more than expected for the gestational age.

Choice B reason: Unilateral, cramp-like abdominal pain is a common manifestation of ectopic pregnancy, because the embryo grows and stretches the fallopian tube, causing inflammation and irritation. The pain may be mild or severe, depending on the size and location of the ectopic pregnancy, and may radiate to the shoulder or back.

Choice C reason: Severe nausea and vomiting is not a specific manifestation of ectopic pregnancy, because it can be caused by other conditions, such as hyperemesis gravidarum, gastroenteritis, or appendicitis. The client may have mild nausea and vomiting due to hormonal changes, but not more than usual for the gestational age.

Choice D reason: Large amount of vaginal bleeding is not a usual manifestation of ectopic pregnancy, because the bleeding is usually internal, into the abdominal cavity. The client may have spotting or light bleeding due to the detachment of the endometrium, but not heavy or profuse bleeding.

A. Contractions occurring every 3 to 5 min B. Each contraction lasting longer than 110 seconds C. Contractions are strong in intensity D. Client reports feeling contractions in lower back

Correct Answer is B

Explanation

Choice A reason: Contractions occurring every 3 to 5 min are normal and expected in the active phase of the first stage of labor, which lasts from 4 to 8 cm of cervical dilation. The nurse does not need to report this finding to the provider.

Choice B reason: Each contraction lasting longer than 110 seconds is abnormal and concerning, as it can indicate uterine hyperstimulation, which can reduce the blood flow to the placenta and fetus, and cause fetal distress. The nurse should report this finding to the provider immediately and prepare for interventions, such as stopping oxytocin infusion, administering tocolytics, or performing an emergency cesarean section.

Choice C reason: Contractions are strong in intensity are also normal and expected in the active phase of the first stage of labor, as they facilitate the cervical dilation and effacement. The nurse does not need to report this finding to the provider.

Choice D reason: Client reports feeling contractions in lower back are common and not harmful, especially if the fetus is in the occiput posterior position, which causes the fetal head to press against the sacrum. The nurse does not need to report this finding to the provider, but can offer comfort measures, such as massage, counterpressure, heat, or position changes.

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A nurse is teaching a client with preterm premature rupture of membranes (PPROM) regarding self-care activities. Which activities should the nurse include in her teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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