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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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Correct Answer is D

Explanation

Choice A rationale

Administering oxygen may help with symptoms like headache and weakness, but it does not address the underlying issue of poor circulation and potential shock. Elevating the legs is more effective in improving blood flow to vital organs.

Choice B rationale

Offering an ice pack is not appropriate for the symptoms described. The client is showing signs of shock, and an ice pack would not address the underlying issue.

Choice C rationale

Providing a warm blanket may offer comfort, but it does not address the symptoms of shock. Elevating the legs is a more direct intervention to improve circulation and stabilize the client.

Choice D rationale

Elevating the client’s legs helps improve venous return to the heart, increasing cardiac output and stabilizing blood pressure. This is a critical intervention for a client showing signs of shock.

Correct Answer is B

Explanation

Choice A rationale

Lying in a left side-lying position for 30 minutes after meals can help reduce heartburn symptoms by preventing stomach acid from flowing back into the esophagus. However, it is not the most effective recommendation for managing heartburn during pregnancy.

Choice B rationale

Taking sips of milk between meals can help neutralize stomach acid and provide relief from heartburn. Milk can act as a buffer, reducing the acidity in the stomach and alleviating discomfort.

Choice C rationale

Eating three large meals per day can exacerbate heartburn symptoms by increasing the amount of stomach acid produced. Smaller, more frequent meals are recommended to help manage heartburn during pregnancy.

Choice D rationale

Drinking a cup of black coffee before breakfast can worsen heartburn symptoms due to its acidic nature and caffeine content. It is not recommended for individuals experiencing frequent heartburn, especially during pregnancy.

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