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 C
Explanation
Choice A rationale
Applying lotion to the newborn’s extremities every 8 hours is not recommended during phototherapy. Lotions and ointments can cause burns when exposed to phototherapy lights and may interfere with the treatment’s effectiveness.
Choice B rationale
Repositioning the newborn every 4 hours is not frequent enough. The newborn should be repositioned every 2 hours to ensure even exposure to the phototherapy light and to prevent pressure sores.
Choice C rationale
Removing the eye mask during feedings is correct. The eye mask should be removed during feedings to allow for bonding and to check for any signs of irritation or infection. This also ensures that the newborn’s eyes are protected from the phototherapy light when not under the lamp.
Choice D rationale
Supplementing feedings with glucose water is not recommended. Breast milk or formula should be used to ensure the newborn receives adequate nutrition and hydration. Glucose water does not provide the necessary nutrients and can interfere with breastfeeding.
Correct Answer is C
Explanation
Choice A rationale
Administering NSAIDs every 4 to 6 hours is not a primary measure to prevent thrombophlebitis. NSAIDs are used for pain relief and inflammation reduction, but they do not directly prevent blood clots.
Choice B rationale
Applying elastic stockings before the client gets out of bed can help prevent blood clots by promoting blood flow in the legs. However, this measure alone is not sufficient to prevent thrombophlebitis.
Choice C rationale
Ambulation, or walking, is one of the most effective measures to prevent thrombophlebitis. It promotes circulation and prevents blood from pooling in the legs, reducing the risk of clot formation.
Choice D rationale
Applying warm, moist packs to the client’s lower legs can help relieve pain and inflammation but does not directly prevent thrombophlebitis. This measure is more supportive rather than preventive.