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":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Explanation

Statement	Include	Not Include
"Your baby needs to be repositioned every 2 to 3 hours while under the lights."	✅
"Your baby's eyes will be covered with an eye shield during therapy."	✅
"Avoid applying lotion to your baby's skin."	✅
"Keep a hat on your baby during treatment."		✅
"We will give your baby glucose water between breast feedings.		✅
"Bilirubin is primarily excreted through the stool."	✅
The treatment lights can cause a transient skin rash on your baby."	✅
The treatment lights emit a significant amount of ultraviolet radiation.		✅

Repositioning every 2 to 3 hours exposes different skin areas to light, enhancing bilirubin breakdown and preventing pressure sores.
Eye shields protect the newborn’s eyes from damage caused by bright phototherapy lights.
Avoiding lotion prevents skin irritation or burns and ensures effective light penetration during treatment.
Keeping a hat on blocks light exposure to the scalp, reducing the effectiveness of phototherapy.
Glucose water is not recommended; feeding with breast milk or formula helps promote bilirubin elimination through stools.
Bilirubin is mainly excreted through the stool after being converted into a water-soluble form by phototherapy.
Phototherapy can cause a mild, temporary rash, which is harmless but important to inform parents about.
Phototherapy lights emit blue light, not harmful ultraviolet radiation, making them safe for newborn treatment.

A. Hypertension B. Bradypnea C. Tachycardia D. Polyuria

Correct Answer is C

Explanation

A. Hypotension, not hypertension, is expected in hemorrhagic shock due to blood loss.
B. Tachypnea, not bradypnea, usually occurs as the body tries to compensate for hypoxia.
C. Tachycardia is an early compensatory response to blood loss to maintain cardiac output.
D. Oliguria (decreased urine output), not polyuria, is expected due to poor perfusion of kidneys in shock.

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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

A nurse is caring for a newborn Exhibits Which of the following statements should the nurse include in the plan of care for the baby

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Explanation

A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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