A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction.

What would the nurse do next?

Notify the primary care provider immediately.

Perform a vaginal exam.

Change the linen saver pad.

Check the fetal heart rate.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Notifying the primary care provider is important but not the immediate next step. The nurse has other immediate responsibilities to ensure the safety of the mother and baby.

Choice B rationale:

A vaginal exam could introduce bacteria into the uterus and is not the immediate next step after rupture of membranes.

Choice C rationale:

Changing the linen saver pad is not the immediate next step. While it might be necessary for the comfort of the mother, it does not address the potential risks associated with rupture of membranes.

Choice D rationale:

Checking the fetal heart rate is the correct next step. This ensures that the baby is not in distress following the rupture of membranes.

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Correct Answer is C

Explanation

Choice A rationale:

Transient fetal hypoxia is not typically associated with cloudy amniotic fluid. It’s a condition where the fetus doesn’t get enough oxygen.

Choice B rationale:

Normal amniotic fluid is clear or light yellow. Cloudy amniotic fluid is not considered normal.

Choice C rationale:

Cloudy amniotic fluid could indicate a possible infection. The cloudiness can be due to the presence of bacteria and inflammatory cells.

Choice D rationale:

Meconium passage can cause the amniotic fluid to become green or brown, not typically cloudy. So, the correct answer for both questions 26 and 27 is C.

A. Cephalhematoma. B. Vertex presentation. C. Caput Succedaneum. D. Molding.

Correct Answer is D

Explanation

Choice A rationale:

A cephalhematoma is a collection of blood that can occur under the scalp of a newborn. It does not aid in the passage of the fetal skull through the birth canal.

Choice B rationale:

Vertex presentation refers to the position of the fetus in the womb, not a feature of the skull that aids in birth.

Choice C rationale:

Caput succedaneum is a swelling of the scalp in a newborn. It is caused by pressure from the uterus or vaginal wall during a head-first (vertex) delivery, not a feature that aids in birth.

Choice D rationale:

Molding refers to the shaping of the fetal skull to fit through the birth canal. This is possible due to the presence of sutures and fontanelles in the skull, which allow the bony plates of the skull to move and overlap.

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A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as:.

Correct Answer is C

Explanation

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

Correct Answer is D

Explanation

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?.

A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome?.

A nurse palpates a woman's fundus to determine contraction intensity. What would be most appropriate for the nurse to use for palpation?.

A pregnant woman is diagnosed with iron deficiency anemia and is prescribed an iron supplement. After teaching her about her prescribed iron supplement, which statement indicates successful teaching?.

A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which factors would the nurse include when discussing measures to promote coping for a positive labor experience? Select all that apply.

A nurse is explaining the fetus's position to a female client whose baby is in the frank breech position. Which statement by the client would indicate that the teaching was understood?.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction.

What would the nurse do next?