A nurse in a provider’s office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.Which of the following manifestations is the priority?
Amniotic fluid with meconium noted.
Maternal temperature 38.3°C (101°F).
Foul smelling vaginal discharge.
Fetal heart tones 98/min.
The Correct Answer is D
Choice A rationale
Amniotic fluid with meconium noted can indicate fetal distress, but it is not the most immediate priority compared to fetal heart tones.
Choice B rationale
A maternal temperature of 38.3°C (101°F) can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice C rationale
Foul-smelling vaginal discharge can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice D rationale
Fetal heart tones of 98/min indicate fetal bradycardia, which is a sign of fetal distress and requires immediate intervention to ensure the well-being of the fetus.
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Correct Answer is B
Explanation
Choice A rationale
The statement about the partner wanting to help but not planning for the baby indicates a lack of acceptance and preparation for the pregnancy. It suggests that the adolescent and their partner may not have fully embraced the reality of the pregnancy.
Choice B rationale
Missing soda but acknowledging that it is better for the baby indicates that the adolescent is making sacrifices and changes for the benefit of the baby. This behavior reflects acceptance of the pregnancy and a willingness to prioritize the baby’s health.
Choice C rationale
Being upset about having to quit school when the baby comes indicates that the adolescent is struggling with the impact of the pregnancy on their life plans. This statement suggests a lack of acceptance and difficulty in adjusting to the pregnancy.
Choice D rationale
Expecting the parents to raise the baby due to being young indicates a lack of acceptance and responsibility for the pregnancy. It suggests that the adolescent may not be fully prepared to take on the role of a parent.
Correct Answer is C
Explanation
Choice A rationale
Nursing the baby for 5 to 10 minutes on each breast may not be sufficient for the baby to receive the hindmilk, which is rich in fat and essential for growth.
Choice B rationale
Applying vitamin E oil to the nipples after each feeding is not recommended as it can cause irritation and is not necessary for nipple care.
Choice C rationale
Laying the baby on a pillow at the level of the breast helps ensure proper positioning and latch, which is crucial for effective breastfeeding and preventing nipple soreness.
Choice D rationale
Ensuring that just the nipple is in the baby’s mouth is incorrect. The baby should latch onto the areola, not just the nipple, to ensure effective milk transfer and prevent nipple pain.