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 ["50"]

Explanation

To calculate the rate at which the infusion pump should be set, we need to determine how many mL of the solution contain 2 grams of magnesium sulfate.

Step 1: First, we find out how many grams of magnesium sulfate are in 1 mL of the solution. The IV bag contains 20 grams of magnesium sulfate in 500 mL, so we divide 20 grams by 500 mL to get the amount of magnesium sulfate per mL: 20 grams ÷ 500 mL = 0.04 grams/mL

Step 2: Next, we find out how many mL contain 2 grams of magnesium sulfate.

We divide 2 grams by the amount of magnesium sulfate per mL: 2 grams ÷ 0.04 grams/mL = 50 mL Therefore, the nurse should set the infusion pump to deliver 50 mL per hour.

A. Remain on clear liquids until the vomiting subsides. B. Take nothing by mouth until there is no more nausea. C. Come to the clinic to be seen by a healthcare provider. D. Make an appointment at the clinic if a fever occurs.

Correct Answer is C

Explanation

Choice A rationale

While remaining on clear liquids until the vomiting subsides may seem like a reasonable approach, it may not be the best course of action for a pregnant woman who has been vomiting for 24 hours. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus.

Choice B rationale

Taking nothing by mouth until there is no more nausea is not advisable in this situation. Nausea can persist even after vomiting has stopped, and it’s important for the woman to stay hydrated and nourished.

Choice C rationale

The best course of action in this situation is for the woman to come to the clinic to be seen by a healthcare provider. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus. In addition, the healthcare provider can assess the woman’s condition and provide appropriate treatment.

Choice D rationale

Making an appointment at the clinic if a fever occurs is not the best advice in this situation. While it’s important to seek medical attention if a fever develops, the woman should not wait for this to happen before seeking help. Prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus, and should be addressed promptly.

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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

Correct Answer is ["50"]

Explanation

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.What instruction should the nurse give to this client?

Correct Answer is C

Explanation

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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?