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 A
Explanation
Choice A rationale
Assessing for vaginal bleeding in PPROM is generally not necessary unless there is an indication of placental issues or other complications. PPROM involves the rupture of
membranes before 37 weeks, primarily requiring monitoring for infection and fetal wellbeing rather than routine bleeding checks.
Choice B rationale
Monitoring for signs of infection is critical after PPROM because the rupture increases the risk of ascending infections. The nurse should diligently assess for fever, foul-smelling
discharge, and other signs of infection to initiate timely interventions, preserving both maternal and fetal health.
Choice C rationale
Checking for cervical dilation in PPROM is important because premature rupture of membranes can lead to preterm labor. Monitoring dilation helps determine if labor is imminent,
influencing decisions regarding maternal and neonatal care to prevent complications from premature birth.
Choice D rationale
Watching for fetal compromise is necessary following PPROM as premature rupture of membranes can lead to umbilical cord compression or other complications affecting fetal oxygenation. Continuous fetal monitoring helps detect early signs of distress, allowing timely intervention to ensure fetal safety.
Correct Answer is D
Explanation
Choice A rationale
Numbness in the toes and heel might suggest nerve involvement but is not a typical sign of deep vein thrombosis (DVT), which involves the veins, not nerves.
Choice B rationale
Pain relieved by dorsiflexion (positive Homan's sign) is not reliable for diagnosing DVT. This symptom is outdated and not considered a definitive sign.
Choice C rationale
Spider-like and purple veins suggest superficial varicose veins, not deep vein thrombosis, which affects deeper veins and presents differently.
Choice D rationale
Swelling, redness, and warmth in the calf are classic signs of DVT due to the inflammation and obstruction of deep veins. These symptoms should prompt immediate medical evaluation and intervention. .