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A woman in labor reports a gush of fluid from her vagina. What is the nurse's first action?
- A. Check the fetal heart rate
- B. Assess the fluid for meconium staining
- C. Perform a sterile vaginal examination
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Check the fetal heart rate. This is the first action to assess the well-being of the fetus after the reported fluid gush, ensuring fetal safety. Checking fetal heart rate is crucial in determining fetal distress. Assessing for meconium staining (B) is important but comes after confirming fetal well-being. Performing a sterile vaginal examination (C) may introduce infection and should be avoided without proper indications. Notifying the healthcare provider (D) is necessary but should follow initial assessment of fetal status.
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A client at 30 weeks' gestation is receiving corticosteroids. What is the primary purpose of this therapy?
- A. To prevent preterm labor.
- B. To enhance fetal lung maturity.
- C. To reduce maternal blood pressure.
- D. To lower blood glucose levels.
Correct Answer: B
Rationale: The correct answer is B: To enhance fetal lung maturity. Corticosteroids given to a client at 30 weeks' gestation help accelerate fetal lung maturation, reducing the risk of respiratory distress syndrome in the newborn. This therapy does not prevent preterm labor but rather prepares the baby's lungs for potential early delivery. It also does not directly impact maternal blood pressure or blood glucose levels. Therefore, the primary purpose of corticosteroid therapy in this scenario is to benefit the baby's lung development, making option B the correct choice.
A client at 39 weeks' gestation reports sudden gush of fluid. What is the nurse's priority action?
- A. Perform a sterile vaginal exam.
- B. Assess fetal heart rate.
- C. Check maternal vital signs.
- D. Administer IV fluids.
Correct Answer: B
Rationale: The correct answer is B: Assess fetal heart rate. The priority action in this situation is to assess the well-being of the fetus since the client reported a sudden gush of fluid, which could indicate rupture of membranes. Assessing the fetal heart rate helps determine if the fetus is experiencing distress. Performing a sterile vaginal exam (A) can introduce infection and is not the priority. Checking maternal vital signs (C) can be done after assessing the fetal well-being. Administering IV fluids (D) is not the priority until the fetal status is determined.
A patient has delivered twins. The first twin was stillborn, and the second is in the intensive care nursery, recovering quickly from respiratory distress. The patient is crying softly and says, "wish my baby could have lived." What is the most therapeutic response?
- A. "How soon do you plan to have another baby?"
- B. "Don't be sad. At least you have one healthy baby."
- C. "have a friend who lost a twin and she's doing just fine now."
- D. "am so sorry about your loss. Would you like to talk about it?"
Correct Answer: D
Rationale: The correct answer is D because it shows empathy, acknowledges the patient's loss, and invites further discussion if the patient wishes to talk. It validates the patient's feelings and offers support. Choice A is inappropriate as it disregards the patient's current emotional state. Choice B diminishes the patient's grief and may come off as insensitive. Choice C redirects the focus to someone else's experience, which may not be helpful in addressing the patient's emotions.
The nurse is caring for a postpartum client who reports feeling overwhelmed and tearful. What is the nurse's priority intervention?
- A. Administer a sedative as prescribed.
- B. Encourage the client to rest and sleep.
- C. Provide emotional support and reassurance.
- D. Refer the client to a mental health professional.
Correct Answer: C
Rationale: The correct answer is C: Provide emotional support and reassurance. This is the priority intervention because the client is feeling overwhelmed and tearful, indicating a need for immediate emotional support. Administering a sedative (A) may mask the underlying issue and is not addressing the client's emotional needs. Encouraging rest and sleep (B) is important but secondary to addressing the client's emotional state. Referring the client to a mental health professional (D) may be necessary in the long term but is not the immediate priority in this situation. Emotional support and reassurance can help the client feel validated and supported in the moment.
A nurse is reviewing a laboratory results for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
- A. BUN 35 mg/dL
- B. Hgb 15 mg/dL
- C. Bilirubin 0.6 mg/dL
- D. Hct 37%
Correct Answer: A
Rationale: The correct answer is A: BUN 35 mg/dL. In preeclampsia, elevated BUN levels indicate impaired kidney function, a serious complication. High BUN can lead to renal damage. Hgb, Hct, and Bilirubin levels are within normal ranges for pregnancy, so they do not indicate a critical issue. Reporting BUN level is crucial for monitoring kidney function and preventing further complications in preeclampsia.