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 B

Explanation

A. IV fluids should be administered cautiously in preeclampsia to avoid fluid overload; an IV bolus is not routinely indicated.
B. Monitoring for clonus is important, as it is a sign of increased neuromuscular irritability and risk of seizure in preeclampsia.
C. Misoprostol is used to manage postpartum bleeding but is not specific to preeclampsia management.
D. Fluid restriction is generally not recommended unless there are signs of fluid overload or other complications.

A. A newborn who has subconjunctival hemorrhage of the left eye B. A newborn who has overlapping suture lines C. A newborn who has nasal flaring D. A newborn who has rust stained urine

Correct Answer is C

Explanation

A. Subconjunctival hemorrhage is common after vaginal delivery and usually harmless.
B. Overlapping suture lines are normal in newborns due to molding during birth.
C. Nasal flaring is a sign of respiratory distress and requires immediate assessment.
D. Rust-stained urine can be due to urate crystals and is usually benign in newborns.

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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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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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