Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
36. A primigravida presents to a labor and delivery unit at 30 weeks' gestation. Her major complaints are abdominal pain, vaginal bleeding, and dysuria. Which interventions or assessments should a nurse perform when caring for this client? Select all that apply.
. Call the physician for pain medication.
. Place the client on an external fetal monitor.
. Obtain a specimen for fern test.
. Obtain a clean-catch urine specimen.
. Perform a vaginal exam for cervical dilation.
Test-Taking Tip
The key to this question is dysuria and preterm. The appropriate interventions for a client who is preterm are different than those for a full-term gestation.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because the client is probably experiencing preterm labor with a urinary tract infection. Calling the physician to convey information about the client's condition would be important, but not specifically for pain medication. Answer 2 is correct because placing the client on an external fetal monitor is standard nursing procedure to evaluate the fetal well-being and the pattern of contractions. With preterm labor, it is important to evaluate uterine activity on the external fetal monitor. Answer 3 is incorrect because the client is not complaining of rupture of membranes. The fern test specifically helps to determine if the amniotic sac is leaking. Answer 4 is correct because the client is complaining of dysuria. Obtaining a clean-catch urine specimen would be appropriate to evaluate the possibility of a urinary tract infection. Answer 5 is incorrect because the client is preterm and has vaginal bleeding. A vaginal exam is contraindicated when the client has vaginal bleeding of unknown origin.