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 A
Explanation
Choice A rationale
Retained placental fragments are a significant risk factor for postpartum hemorrhage. If parts of the placenta remain attached to the uterine wall, it can prevent the uterus from contracting properly, leading to excessive bleeding.
Choice B rationale
Breech presentation is not a direct risk factor for postpartum hemorrhage. While it can complicate delivery, it does not directly cause hemorrhage.
Choice C rationale
Urinary tract infection is not a risk factor for postpartum hemorrhage. It can cause other complications but does not directly lead to hemorrhage.
Choice D rationale
Oligohydramnios, or low amniotic fluid, is not a risk factor for postpartum hemorrhage. It can cause complications during pregnancy but does not directly lead to hemorrhage.
Correct Answer is A
Explanation
Choice A rationale
Warming the newborn’s heel for 5 to 10 minutes before the puncture increases blood flow, making it easier to collect a blood sample.
Choice B rationale
The outer aspect of the heel is the recommended site for puncture to avoid injury to the bone and nerves.
Choice C rationale
Leaving the heel open to the air after the puncture is not recommended as it can increase the risk of infection.
Choice D rationale
Applying an antiseptic after collecting the specimen is not necessary and can interfere with the blood sample.