A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
Estimated amount of fluid.
Color and consistency of fluid.
Time the membranes ruptured
Any odor noted when membranes ruptured
The Correct Answer is C
A. Estimated amount of fluid:
Knowing the estimated amount of amniotic fluid can provide some information, but it may not be as crucial as other factors in this situation. The primary concern is often related to the color and odor of the amniotic fluid to assess for potential issues.
B. Color and consistency of fluid:
This is a crucial piece of information. The color and consistency of amniotic fluid can provide important clues about fetal well-being and the presence of meconium, which may indicate fetal distress.
C. Time the membranes ruptured:
Knowing the time when the membranes ruptured is essential for assessing the duration of time since the rupture. This information helps in determining the risk of infection, which is a concern after prolonged rupture of membranes.
D. Any odor noted when membranes ruptured:
This is also a critical piece of information. An unpleasant odor, especially if it is foul-smelling, could be indicative of infection. Infection risk increases with prolonged rupture of membranes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cries vigorously when stimulated:
Explanation: Vigorous crying is a positive sign in a newborn. It indicates that the baby is responsive, breathing effectively, and is capable of establishing the necessary air exchange.
B. A positive Babinski reflex:
Explanation: The Babinski reflex is a normal reflex in infants where the toes spread out when the sole of the foot is stimulated. While it is a normal reflex in newborns, it might not necessarily indicate the immediate transition to extrauterine life.
C. Heart rate of 220 beats/minute:
Explanation: A heart rate of 220 beats per minute in a newborn is higher than the normal range. It could be a sign of tachycardia, and this finding might require further evaluation by healthcare providers.
D. Flexion of all four extremities:
Explanation: Flexion of extremities is a normal response in a newborn, but it might not specifically indicate successful transition. It's a common response seen in healthy newborns.
Correct Answer is C
Explanation
A. Avoid alcohol, caffeine, and smoking: This is generally good advice during pregnancy to promote a healthy environment for the developing fetus, but it may not specifically address nausea.
B. Eliminate between meal snacks: While this might be suggested for some individuals, keeping something light on the stomach, like crackers, can sometimes help alleviate nausea.
C. Practice relaxation techniques when the nausea first begins: Relaxation techniques, such as deep breathing or meditation, can be beneficial in managing nausea, especially if stress or anxiety contributes to the symptoms.
D. Increase intake of fluids to 3 quarts daily: Staying hydrated is important during pregnancy, but drinking too much fluid at once might not necessarily alleviate nausea and could potentially make it worse.
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