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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Bradypnea and hypertension are not typically signs of impending shock.
Choice B rationale:
Tachycardia and a falling blood pressure are classic signs of shock as the body tries to compensate for the decreased blood flow.
Choice C rationale:
Tachypnea and a widening pulse pressure can be signs of shock, but they are not as indicative as tachycardia and a falling blood pressure.
Choice D rationale:
Bradycardia and auscultation of fluid in the base of the lungs are not typically signs of impending shock.
Correct Answer is C
Explanation
Choice A rationale:
Contractions every 1 minute and cervical dilation of 9 cm are indicative of the transition phase of labor.
Choice B rationale:
Contractions every 2 1/2 minutes and cervical dilation of 8 cm are indicative of the active phase of labor.
Choice C rationale:
Contractions every 5 minutes and cervical dilation of 3 cm are indicative of the latent phase of labor.
Choice D rationale:
Contractions every 3 minutes and cervical dilation of 6 cm are indicative of the active phase of labor.
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