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 D

Explanation

This is based on the fact that HIV is a virus that attacks the body’s immune system and is spread through certain body fluids, including breast milk.Perinatal transmission can occur during pregnancy, birth, or breastfeeding.Treatment for HIV (antiretroviral therapy, or ART) substantially reduces the risk of perinatal transmission.

Choice A is wrong because sterilizing breast milk does not kill the HIV virus.

Choice B is wrong because colostrum can also contain the HIV virus and testing it is not feasible or reliable.

Choice C is wrong because breastfeeding may still pose a risk of HIV transmission even if the infant is determined to be HIV positive.

The current recommendation in the United States supports shared decision-making between mothers and their healthcare providers regarding infant feeding.Mothers who have questions about breastfeeding or who want to breastfeed should receive patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.

Counseling should begin before conception, or as early as possible in pregnancy and should be

A. Assess the patient’s urine for acetone. B. Monitor the patient’s deep tendon reflexes. C. Assess the patient’s pupillary accommodation. D. Monitor the patient’s blood pressure.

Correct Answer is D

Explanation

This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.

The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.

Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia.Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.

However, this is not related to epidural anesthesia.

Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia.Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).

However, this is not related to epidural anesthesia.

Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.

Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects.It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.

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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?

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Naxlex Comprehensive Predictor Exams

A mother of a 3-hour-old infant requests information concerning breastfeeding. The mother has tested positive for human immunodeficiency virus (HIV).A nurse’s response should be based on which fact?

Correct Answer is D

Explanation

A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction. The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?

Correct Answer is D

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?