A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.
She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

Estimated amount of fluid.

Any odor noted when membranes ruptured.

Time the membranes ruptured.

Color and consistency of fluid.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While the estimated amount of fluid can provide some information about the volume of amniotic fluid lost, it is not the most critical piece of information. The amount of fluid can vary and does not necessarily indicate the progression of labor.

Choice B rationale

Any odor noted when the membranes ruptured can be a sign of infection. However, this is not the most crucial information to obtain immediately as it does not directly impact the management of labor.

Choice C rationale

The time the membranes ruptured is the most important information to obtain. This is because the risk of infection increases the longer the time between membrane rupture and delivery.

Knowing the time of rupture helps guide decisions about inducing labor and administering antibiotics to prevent infection.

Choice D rationale

The color and consistency of the fluid can provide information about the presence of meconium or blood, which could indicate fetal distress or placental problems. However, this is not the most critical information to obtain immediately.

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Correct Answer is D

Explanation

Choice A rationale

Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.

Choice B rationale

Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.

Choice C rationale

Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.

Choice D rationale

Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.

A. Reassure the client that the AFP results could be a false reading. B. Discuss options for intrauterine surgical correction of congenital defects. C. Inform her that a repeat AFP test should be conducted. D. Explain that a sonogram should be scheduled for definitive results.

Correct Answer is D

Explanation

Choice A rationale

While it’s true that AFP results can sometimes be false readings, it’s not the most appropriate advice for the nurse to give in this situation. Simply reassuring the client without suggesting further investigation could potentially overlook a serious condition.

Choice B rationale

Discussing options for intrauterine surgical correction of congenital defects at this stage is premature. The elevated AFP level alone does not confirm the presence of congenital defects, and suggesting surgical intervention may cause unnecessary anxiety.

Choice C rationale

Informing the client that a repeat AFP test should be conducted is a reasonable suggestion. However, it’s not the most appropriate next step in this case. A repeat test would provide more information, but it wouldn’t give definitive results about the cause of the elevated AFP level.

Choice D rationale

Explaining that a sonogram should be scheduled for definitive results is the most appropriate advice. An ultrasound can provide a more detailed view of the fetus and help identify any potential issues that might have led to the elevated AFP level. This would be the most informative next step and would guide further actions based on the findings.

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A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

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A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.
She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?