The nurse in a prenatal clinic is assessing a patient who is at 37 weeks' gestation for twins. The patient reports increased discomfort and increased lower pelvic pressure.
Which action does the nurse take with this patient?
Explains to the patient that increased discomfort is expected with twins.
Performs a digital cervical examination to determine if dilation is occurring.
Sends the patient to the hospital to be checked for possible signs of labor.
After examination, assures the patient of the absence of contractions.
The Correct Answer is C
Choice A rationale
While it’s true that increased discomfort is expected with twins due to additional physical strain and space constraints, this alone is not sufficient reassurance. It is vital to assess for
signs of preterm labor or other complications.
Choice B rationale
Performing a digital cervical examination is a valid approach to checking for dilation, but this action must be carefully considered based on other signs and symptoms presented by
the patient. The focus here is on ensuring the absence or presence of labor, which might require hospital assessment.
Choice C rationale
Sending the patient to the hospital to be checked for possible signs of labor ensures that professional monitoring and interventions can occur if labor is confirmed. This action
prioritizes safety, given the increased risk of complications with twin pregnancies and the advanced gestation of 37 weeks.
Choice D rationale
Assuring the patient of the absence of contractions after an examination might provide temporary relief, but it does not address the possibility of other signs of labor or complications
that may require more comprehensive hospital assessment.
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Correct Answer is D
Explanation
Choice A rationale
Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.
Choice B rationale
Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.
Choice C rationale
Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.
Choice D rationale
Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.
Correct Answer is C
Explanation
Choice A rationale
The hemoglobin level of 11.6 g/dL is within the normal range for a pregnant woman. While placenta previa requires monitoring, it is not immediately life-threatening.
Choice B rationale
Type 2 diabetes mellitus requires regular monitoring and management, but a single fasting blood glucose level does not indicate an immediate emergency unless it is extremely high or low.
Choice C rationale
Partial placental abruption can lead to significant complications for both the mother and fetus, including hemorrhage and fetal distress, making it the priority for immediate assessment.
Choice D rationale
An Rh-negative status and a recent cerclage placement are important for ongoing monitoring but do not present an immediate life-threatening condition that demands the first assessment.