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 C
Explanation
Choice A rationale:
This is incorrect. Intercourse is unlikely to cause rupture of membranes.
Choice B rationale:
This is also incorrect. Intercourse is not likely to result in premature labor.
Choice C rationale:
This is correct. It is generally safe to have intercourse during an uneventful pregnancy.
Choice D rationale:
This is also correct. There are other ways to satisfy sexual needs if intercourse is not possible or desired.
Correct Answer is B
Explanation
Choice A rationale:
Dysuria is not typically associated with lightening.
Choice B rationale:
Urinary frequency can increase when lightening occurs because the baby drops into the pelvis, putting more pressure on the bladder.
Choice C rationale:
Constipation is not typically associated with lightening.
Choice D rationale:
Dyspnea can actually improve when lightening occurs because there is less pressure on the diaphragm.
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