A patient’s amniotic fluid is meconium-stained. Which action should the nurse plan to take?
Take the mother’s vital signs every 15 minutes.
Send a specimen of the fluid to the laboratory for analysis.
Have a suction catheter available for use at delivery.
Prepare a slide of the fluid for fern testing.
The Correct Answer is C
The correct answer is choice C. Have a suction catheter available for use at delivery. This is because meconium-stained amniotic fluid indicates that the fetus has passed meconium (first stool) before birth, which can be a sign of fetal distress or hypoxia. Meconium can block the airways and cause breathing problems for the newborn, so suctioning the mouth and nose (or the trachea if needed) is important to prevent meconium aspiration syndrome.
Choice A is wrong because taking the mother’s vital signs every 15 minutes is not a specific intervention for meconium-stained amniotic fluid.
Vital signs should be monitored regularly during labor regardless of the fluid color.
Choice B is wrong because sending a specimen of the fluid to the laboratory for analysis is not a priority action.The color and consistency of the fluid can be observed by the nurse and documented.
The laboratory analysis will not change the immediate management of the newborn.
Choice D is wrong because preparing a slide of the fluid for fern testing is not relevant for meconium-stained amniotic fluid.
Fern testing is used to confirm the rupture of membranes by detecting a fern-like pattern of amniotic fluid under a microscope.It is not useful for assessing the presence or severity of meconium-stained amniotic fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. A patient who weighed less than 5 lb (2,268 gm) at birth is at risk for having an infant with intrauterine growth retardation (IUGR).This is because low birth weight is a possible indicator of genetic factors or placental insufficiency that can affect fetal growth.
Choice B is wrong because an ectopic pregnancy one year ago does not increase the risk of IUGR.An ectopic pregnancy is when the fertilized egg implants outside the uterus, usually in the fallopian tube.It does not affect the placental function or fetal development in a subsequent pregnancy.
Choice C is wrong because a mitral valve prolapse does not increase the risk of IUGR.
A mitral valve prolapse is when the valve between the left atrium and left ventricle of the heart does not close properly.It usually does not cause any symptoms or complications during pregnancy, unless it is associated with severe regurgitation or arrhythmias.
Choice D is wrong because the father’s age of 42 years old does not increase the risk of IUGR.The father’s age may affect the risk of chromosomal abnormalities or congenital anomalies in the fetus, but not the fetal growth.
Some of the other risk factors for IUGR include maternal smoking, alcohol, or drug use, medical conditions like anemia or lupus, infections such as rubella or syphilis, carrying twins or multiples, high blood pressure, gestational diabetes, and placenta problems.
Correct Answer is C
Explanation
The correct answer is choice C. Assess the client’s blood pressure.Methylergonovine is a uterotonic medication that can cause hypertension and is contraindicated for clients with preeclampsia or cardiac disease.
Therefore, the nurse should check the client’s blood pressure before administering this medication to ensure it is within normal range (120/80 mm Hg or lower).
Choice A is wrong because assessing the client’s pain scale is not a priority assessment before giving methylergonovine.
Pain is not a contraindication for this medication and does not affect its effectiveness.
Choice B is wrong because assessing the client’s respiratory rate is not a priority assessment before giving methylergonovine.
Respiratory rate is not affected by this medication and does not indicate any adverse effects.
Choice D is wrong because assessing the client’s last bowel movement is not a priority assessment before giving methylergonovine.
Bowel movement is not related to postpartum hemorrhage or uterine atony, which are the indications for this medication.
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