A client at 40 weeks' gestation should be instructed to go to a ...

[EAugust]

A client at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:
 
  a. fetal movement.
  b. irregular contractions for 1 hour.
  c. a trickle of fluid from the vagina.
  d. thick pink or dark red vaginal mucus.

Question 2

A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are:
 
  a. contraction pattern, amount of discomfort, and pregnancy history.
  b. fetal heart rate, maternal vital signs, and the woman's nearness to birth.
  c. last food intake, when labor began, and cultural practices the couple desires.
  d. identification of ruptured membranes, the woman's gravida and para, and her support person.

[Viet Thy]

Answer to Question 1

ANS: C
A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

Answer to Question 2

ANS: B
All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the woman's gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

[EAugust]

TYSM

[nguyenhoanhat]

Excellent