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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?

A.

Amniotic fluid with meconium noted.

B.

Maternal temperature 38.3°C (101°F).

C.

Foul smelling vaginal discharge.

D.

Fetal heart tones 98/min.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

There is no need to fast before a nonstress test. The test measures the fetal heart rate in response to fetal movements and does not require any dietary restrictions.

Choice B rationale

During a nonstress test, the client will press a button whenever they feel the baby move. This helps correlate fetal movements with heart rate changes.

Choice C rationale

The client is not required to lie flat on their back for the duration of the test. They can be in a semi-reclined position to ensure comfort and avoid supine hypotensive syndrome.

Choice D rationale

Medication to stimulate contractions is not used during a nonstress test. This is done during a contraction stress test, which is a different procedure.

Correct Answer is D

Explanation

Choice A rationale

Using a breast pump can help maintain milk supply if the client plans to return to work, but it does not directly prevent mastitis.

Choice B rationale

Covering the breasts immediately after feedings is not necessary and does not prevent mastitis. Proper hygiene and feeding techniques are more important.

Choice C rationale

Wearing an underwire bra can restrict milk flow and increase the risk of mastitis. A well-fitting, non-restrictive bra is recommended.

Choice D rationale

Washing nipples with soap and water daily can cause dryness and irritation, increasing the risk of mastitis. It is better to clean the nipples with water only and ensure proper latch and feeding techniques. .

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