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 B
Explanation
Swallowing a preprocedure sedative is not typically required for an amniocentesis. Sedatives can affect the mother and the fetus, and are usually avoided unless absolutely necessary.
Choice B rationale:
Emptying the bladder is important before an amniocentesis. A full bladder can push against the uterus, increasing the risk of puncturing the bladder during the procedure.
Choice C rationale:
Showering with an antiseptic scrub is not typically required before an amniocentesis. The area of the abdomen where the needle will be inserted is usually cleaned with an antiseptic by the healthcare provider.
Choice D rationale:
Lying on the left side is not typically required for an amniocentesis. The procedure is usually performed with the woman lying on her back.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
The vagina is not part of the true pelvis. It is the canal that leads from the uterus to the exterior of the body.
Choice B rationale:
The pelvic inlet is the upper part of the lesser pelvis where the baby’s head engages during labor. It is part of the true pelvis.
Choice C rationale:
The pelvic outlet is the lower opening of the pelvis. It is part of the true pelvis.
Choice D rationale:
The mid pelvis is the part of the pelvis where the baby turns to get into the right position for birth. It is part of the true pelvis.
Choice E rationale:
The pelvic floor muscles support the pelvic organs and help in the process of childbirth. They are part of the true pelvis.
Choice F rationale:
The cervix is the lower part of the uterus that opens into the vagina. It is not part of the true pelvis. So, the correct answers are B, C, D, and E.
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