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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Remind the patient that the nurse will stay with her during the examination.
This measure would help reduce the patient’s anxiety by providing emotional support and reassurance.
The patient may feel scared, embarrassed, or vulnerable during the pelvic examination, especially since she is young and pregnant.
Having a trusted person with her can help her cope with these feelings.
Choice A is wrong because it may imply that the examination will be painful and increase the patient’s anxiety.
Choice B is wrong because it may make the patient feel like she is not being treated as an individual and that her concerns are not valid.
Choice D is wrong because it may make the patient feel rushed or pressured and not allow her to ask questions or express her feelings.
Correct Answer is C
Explanation
The correct answer is choice C. The patient should palpate her breasts using the padded sections of her fingers.This is the recommended technique for breast self-examination, as it allows the patient to feel any changes or lumps in the breast tissue.
Choice A is wrong because the patient should perform breast self-examination at the same time each month, preferably a few days after the menstrual period ends when the breasts are less likely to be swollen or tender.
Choice B is wrong because the patient should not assume that any lumps that are present in both breasts are normal.Some breast cancers can affect both breasts, and any new or unusual lumps should be reported to a doctor.
Choice D is wrong because the patient should look at her breasts while standing in front of the mirror with her arms at her sides, raised overhead, and pressed firmly on her hips.She should also look for any changes in the shape, size, color, or texture of her breasts and nipples.
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