A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction.
What would the nurse do next?
Notify the primary care provider immediately.
Perform a vaginal exam.
Change the linen saver pad.
Check the fetal heart rate.
The Correct Answer is D
Choice A rationale:
Notifying the primary care provider is important but not the immediate next step. The nurse has other immediate responsibilities to ensure the safety of the mother and baby.
Choice B rationale:
A vaginal exam could introduce bacteria into the uterus and is not the immediate next step after rupture of membranes.
Choice C rationale:
Changing the linen saver pad is not the immediate next step. While it might be necessary for the comfort of the mother, it does not address the potential risks associated with rupture of membranes.
Choice D rationale:
Checking the fetal heart rate is the correct next step. This ensures that the baby is not in distress following the rupture of membranes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Implementing measures for a vaginal birth is a reasonable intervention as the baby is in a favorable position for a normal delivery.
Choice B rationale:
Continuous internal fetal monitoring is not necessary unless there are complications or high-risk factors present.
Choice C rationale:
Artificial rupture of the membranes can be done to induce or augment labor, but it’s not necessary in this case.
Choice D rationale:
Preparing for a cesarean birth is not necessary as the baby is in a favorable position for a vaginal birth.
Correct Answer is ["mLs\/hr."]
Explanation
Answer and explanation
Step 1 is to calculate the total units of Heparin in 1 mL of the solution. This is done by dividing the total units of Heparin in the bag (40,000 units) by the total volume of the bag (500 mL). So, 40,000 units ÷ 500 mL = 80 units/mL. Step 2 is to calculate the rate at which the IV pump should be set. This is done by dividing the ordered amount of Heparin per hour (1600 units) by the units of Heparin per mL (80 units/mL). So, 1600 units/hr ÷ 80 units/mL = 20 mL/hr.
So, the correct answer is 20 mL/hr.
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