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
Feeding the baby six times a day is not sufficient. Newborns typically need to be fed 8-12 times in 24 hours to ensure they receive adequate nutrition and to establish a good milk supply.
Choice B rationale
Recognizing that the baby sucking on his hands is a hunger cue is correct. This is an early sign of hunger, and responding to these cues helps ensure the baby is fed before becoming too upset.
Choice C rationale
Feeding the baby for 10 minutes on each breast may not be adequate. The duration of feeding can vary, and it is important to allow the baby to feed until they are satisfied, which may take longer than 10 minutes.
Choice D rationale
Waking the baby at least every 6 hours at night for feedings is not recommended. Newborns should be fed more frequently, typically every 2-3 hours, including during the night, to ensure they receive enough nutrition.
Correct Answer is D
Explanation
Choice A rationale
Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.
Choice B rationale
Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.
Choice C rationale
Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.
Choice D rationale
Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.