A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital." Which of the following actions should the nurse take first?

Monitor cervical dilation.

Ask the client about the color of the water.

Obtain the client's vaginal pH.

Determine the fetal heart rate.

Answer and Explanation

The Correct Answer is D

A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.

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Correct Answer is A

Explanation

A. Administering methylergonovine (Methergine) intramuscularly is appropriate for treating postpartum hemorrhage, as it stimulates uterine contractions to help control bleeding.
B. The knee-chest position is not indicated for postpartum hemorrhage and does not address the underlying cause.
C. Oxygen may be necessary if the client is unstable, but 2 L/min via nasal cannula is not the primary intervention and may not be sufficient in a critical situation.
D. Dextrose water is not appropriate for fluid resuscitation during hemorrhage; isotonic fluids like normal saline or lactated Ringer’s are preferred to restore volume.

A. 1 will expect my baby's umbilical cord to fall off in a couple of weeks." B. 1 will give my baby a tub bath once daily C. "I will place my baby on their side to sleep." D. 1 will compress the bulb syringe after I place it in my baby's mouth.”

Correct Answer is A

Explanation

A. The umbilical cord typically dries and falls off within 1 to 2 weeks after birth, which is a normal expectation.
B. Newborns do not need daily tub baths; a sponge bath 2–3 times a week is usually sufficient until the cord falls off.
C. Babies should always be placed on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS), not on their sides.
D. The correct technique for using a bulb syringe is to compress it before inserting it into the baby’s mouth or nose, then release to suction out secretions.

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A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital." Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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