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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?

A.

Check fetal heart tones.

B.

Prepare for a cesarean birth.

C.

Check the color, amount, and odor of the fluid.

D.

Perform Nitrazine test to assess for rupture of membranes.

Answer and Explanation

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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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

  1. Administration of IV fluids: This is anticipated as it ensures the client remains well-hydrated, which is important for both maternal and fetal health.
  2. Continuous monitoring of FHR: This is anticipated to monitor the fetal well-being and ensure there are no signs of fetal distress.
  3. Abdominal ultrasound: This is anticipated to assess fetal growth, amniotic fluid levels, and placental positioning.
  4. Digital cervical exam to assess dilation and effacement: This is contraindicated because frequent cervical exams can increase the risk of infection and may cause unnecessary discomfort, especially if there are no signs of labor.
  5. Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies: These tests are anticipated to provide important information about the client's blood count, blood type, Rh status, and coagulation parameters, which are crucial for managing potential complications.
  6. Placement of an internal fetal spiral electrode: This is contraindicated as it is an invasive procedure that carries risks, and it is unnecessary given that the FHR is within normal limits with external monitoring.
  7. Administration of betamethasone: This is anticipated as betamethasone is often given to promote fetal lung maturity in cases where there is a risk of preterm birth.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Based on the assessment findings, the nurse identifies that the client is at greatest risk for developing:

  1. Postpartum infection
  2. Hemorrhage

Here's the

  • Postpartum infection: The client has a history of prolonged rupture of membranes and is experiencing a moderate amount of lochia rubra, both of which increase the risk of infection. Additionally, she reports feeling weak, fatigued, and has a temperature of 38.5°C (101.3°F), which are signs of a possible infection.
  • Hemorrhage: The moderate amount of lochia rubra and a boggy fundus above the umbilicus indicate that the client may be at risk for postpartum hemorrhage. The provider's prescription for administering oxytocin if needed also suggests a concern for uterine atony, which can lead to hemorrhage.

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