A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously.
Which action should the nurse take next?

Check the specific gravity of the amniotic fluid.

Provide dry linens for the patient.

Auscultate the fetal heart sounds.

Notify the health care provider.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Auscultate the fetal heart sounds. This is because spontaneous rupture of membranes (SROM) may be associated with fetal distress or cord prolapse, and the nurse should assess the fetal well-being as soon as possible. Fetal heart sounds can indicate the presence of fetal bradycardia, tachycardia, or decelerations, which may require immediate intervention.

Choice A is wrong because checking the specific gravity of the amniotic fluid is not a priority action after SROM. The specific gravity can help differentiate amniotic fluid from urine, but it is not as reliable as other methods such as nitrazine paper test or visual inspection.

Choice B is wrong because providing dry linens for the patient is a comfort measure, but not a priority action after SROM. The nurse should first ensure the safety of the fetus and the mother before attending to their comfort needs.

Choice D is wrong because notifying the health care provider is an important action after SROM, but not the first one. The nurse should gather relevant data such as fetal heart rate, maternal vital signs, and characteristics of the fluid before contacting the provider.

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Correct Answer is B

Explanation

The correct answer is choice B. She works as a part-time oncology nurse.This is because oncology nurses are exposed toteratogenic agents, which are substances that can cause abnormalities in an exposed fetus.Teratogenic agents can cross the placenta and alter fetal morphology or function.Examples of teratogenic agents are lead, methyl mercury, polychlorinated biphenyls, lithium, vitamin K antagonists, tobacco, rubella, cytomegalovirus, ionizing agents, hyperthermia, diabetes, and some drugs.

Choice A is wrong because living with two dogs at home does not pose a high risk for exposure to teratogenic agents.Dogs can be beneficial for pregnant women as they provide companionship and exercise.

Choice C is wrong because being a lacto-ova vegetarian does not pose a high risk for exposure to teratogenic agents.Lacto-ova vegetarians can get adequate nutrition from plant-based foods, dairy products, and eggs.

Choice D is wrong because commuting to work on a train does not pose a high risk for exposure to teratogenic agents.Trains are a safe and convenient mode of transportation for pregnant women.

A. “I’ll elevate my legs to relieve my leg cramps.”. B. “My husband will massage my legs when I get cramps.”. C. “Stretching my legs and pointing my toes toward my knee will bring relief from the leg cramps.” D. “I’ll put a cold compress on the calf of my leg when I get a cramp.”.

Correct Answer is C

Explanation

The correct answer is choice C. Stretching your legs and pointing your toes toward your knee will bring relief from the leg cramps.This is because stretching can help relax the muscle and ease the spasm.

Choice A is wrong because elevating your legs may not help with leg cramps, and may actually worsen them by reducing blood flow to the muscles.

Choice B is wrong because massaging your legs may not be enough to relieve the cramps, and may also cause more pain if done too hard or too fast.

Choice D is wrong because putting a cold compress on the calf of your leg may not be effective for leg cramps, and may also cause more discomfort or inflammation.

Leg cramps are common during pregnancy, especially in the second and third trimester.They are caused by various factors, such as pregnancy weight gain, changes in blood circulation, pressure on the nerves and blood vessels, nutrient deficiency, lack of exercise, or fluid buildup in your legs.To prevent or reduce leg cramps, you should drink plenty of water, stay active, eat a balanced diet rich in calcium, magnesium, and potassium, avoid standing or sitting for long periods of time, wear comfortable shoes and socks, and sleep on your left side with a pillow under or between your legs.

If leg cramps persist or become severe, you should consult your healthcare provider for possible treatment options.

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A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient comes to the antepartal clinic for her visit and provides the nurse with information. What piece of information places this patient at high risk for exposure to teratogenic agents?

Correct Answer is B

Explanation

During a regular clinic visit, a patient who is 28 weeks pregnant reports leg cramps. The nurse teaches the patient measures to relieve the cramps. Which statement would indicate that the patient understands the teaching?

Correct Answer is C

Explanation

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A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously.
Which action should the nurse take next?