A laboring client's membranes have just ruptured. What is the nurse's next action?
Assess the client's blood pressure.
Assess the fetal heart rate pattern.
Take the client's temperature.
Prepare for a c-section.
The Correct Answer is B
Assess the fetal heart rate pattern.
Choice B rationale:
When a laboring client's membranes have just ruptured, the nurse's next action should be to assess the fetal heart rate pattern. Rupture of membranes can lead to changes in amniotic fluid, which can affect the fetal environment and potentially cause fetal distress. By assessing the fetal heart rate pattern, the nurse can determine if the baby is tolerating the labor process well or if there are signs of fetal compromise that require further intervention.
Choice A rationale:
While assessing the client's blood pressure (Choice A) is important during labor, it is not the immediate next action when the membranes have ruptured.
Choice C rationale:
Taking the client's temperature (Choice C) is also important, but it is not the priority action when the membranes have ruptured.
Choice D rationale:
Preparing for a c-section (Choice D) is not the initial action unless there are specific indications for an emergency cesarean section. Assessing the fetal heart rate is more critical at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.
Choice B rationale:
The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.
Choice C rationale:
The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.
Choice D rationale:
This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.
Correct Answer is B
Explanation
Choice A rationale:
An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. Normal axillary temperature for a newborn is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice B rationale:
This is the correct choice. Nasal flaring in a newborn is a concerning sign and may indicate respiratory distress. It suggests that the baby is having difficulty breathing and should be reported to the provider for further evaluation.
Choice C rationale:
A heart rate of 158/min is within the normal range for a newborn. The normal heart rate for a newborn can range from 100 to 160 beats per minute.
Choice D rationale:
Having one void since birth is not a concerning finding for a 10-hour-old newborn. In the early hours of life, the frequency of voids may vary, but the baby should have an increasing number of wet diapers in the following days.
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