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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?

A.

Explains to the patient that increased discomfort is expected with twins.

B.

Performs a digital cervical examination to determine if dilation is occurring.

C.

Sends the patient to the hospital to be checked for possible signs of labor.

D.

After examination, assures the patient of the absence of contractions.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

Choice A rationale

While intravenous antibiotics are given during labor to prevent GBS transmission to the baby, it is not administered at home but in the hospital when labor begins.

Choice B rationale

GBS does not significantly increase the risk of intrauterine infection that requires daily temperature checks; it primarily poses a risk of neonatal infection during delivery.

Choice C rationale

GBS bacteria reside in the vagina and can be transmitted to the baby during delivery. Administering antibiotics during labor helps protect the baby from serious GBS-related illnesses.

Choice D rationale

GBS does not cause scarlet fever or the symptoms described; those are caused by different bacteria, namely Streptococcus pyogenes. .

Correct Answer is D

Explanation

Choice A rationale

Placental abruption is characterized by abdominal pain, vaginal bleeding, and uterine tenderness. It does not cause dyspnea, hypotension, frothy sputum, or loss of consciousness.

Choice B rationale

Uterine rupture typically presents with severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Shock can occur, but not frothy sputum or sudden dyspnea.

Choice C rationale

Uterine inversion leads to pain, hemorrhage, and shock. It does not present with frothy sputum or sudden dyspnea.

Choice D rationale

Anaphylactoid syndrome (amniotic fluid embolism) results from amniotic fluid entering maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, matching the described scenario. .

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