A client who is in active labor is admitted to a labor and delivery unit reporting "My water just broke and my baby is breech.”. Which of the following actions should the nurse take first?
Check fetal heart tones.
Prepare for a cesarean birth.
Check the color, amount, and odor of the fluid.
Perform Nitrazine test to assess for rupture of membranes.
The Correct Answer is A
Choice A rationale
Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.
Choice B rationale
Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.
Choice C rationale
Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.
Choice D rationale
Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Taking iron supplements with milk is not advised because calcium in milk can interfere with the absorption of iron, reducing its effectiveness.
Choice B rationale
Doubling the dose of iron supplements if a dose is missed is not recommended because it can cause gastrointestinal issues and toxicity. It's better to just continue with the regular dosing schedule.
Choice C rationale
Consuming 29 grams of fiber daily is a good practice for overall health, but it does not directly aid in iron absorption. Fiber can actually bind to iron and decrease its absorption in the intestines.
Choice D rationale
Vitamin C enhances the absorption of non-heme iron (found in supplements) by converting it into a more absorbable form. Taking vitamin C with iron supplements increases their effectiveness, making this statement correct.
Correct Answer is C
Explanation
Choice A rationale
A positive finding for galactosemia, not PKU, indicates the inability to metabolize galactose. Galactosemia is a different metabolic disorder that requires a separate dietary intervention.
Choice B rationale
A positive PKU test does not indicate slow metabolism. Instead, it signifies the inability to metabolize phenylalanine, an amino acid.
Choice C rationale
Phenylketonuria (PKU) is a genetic disorder that leads to the inability to break down the amino acid phenylalanine. Without proper management, it can accumulate in the body and cause brain damage and other health issues.
Choice D rationale
A positive PKU test is not directly linked to an increased risk for neurological anomalies in general. The specific issue in PKU is the inability to metabolize certain amino acids, primarily phenylalanine, which can cause neurological damage if untreated. .
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