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.Choice C is wrong because having more than three full-term pregnancies does not affect the suitability of using a copper IUD as a birth control method.Copper IUDs are long-term, reversible contraceptives that can be used by premenopausal women of all ages, including those who have never been pregnant or who have had multiple pregnancies.
Choice A is correct because a copper IUD can be inserted anytime during a normal menstrual cycle, or up to eight weeks after childbirth.
Choice B is correct because a copper IUD may cause heavier and longer periods, as well as more cramping.
Choice D is correct because a copper IUD works by creating an inflammatory response in the uterus that prevents sperm from reaching the egg and fertilizing it, and also prevents a fertilized egg from implanting in the uterine wall.
Correct Answer is C
Explanation
This is because pregnancy-induced hypertension (PIH) can cause eclampsia, a condition characterized by seizures and coma.Eclampsia can occur during pregnancy, labor, or postpartum.
A nurse should monitor the client for signs of increased blood pressure, headache, blurred vision, epigastric pain, and hyperreflexia, which may indicate an impending convulsion.
Choice A is wrong because hemorrhage is not a common complication of PIH.
Hemorrhage may occur due to other causes such as uterine atony, lacerations, or retained placenta.
Choice B is wrong because urinary retention is not a common complication of PIH.
Urinary retention may occur due to other causes such as anesthesia, trauma, or infection.
Choice D is wrong because thrombophlebitis is not a common complication of PIH.
Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation.
It may occur due to other risk factors such as immobility, dehydration, or injury.
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