A laboring client's membranes have just ruptured. What is the nurse's next action?

Assess the client's blood pressure.

Assess the fetal heart rate pattern.

Take the client's temperature.

Prepare for a c-section.

Answer and Explanation

The Correct Answer is B

Assess the fetal heart rate pattern.

Choice B rationale:

When a laboring client's membranes have just ruptured, the nurse's next action should be to assess the fetal heart rate pattern. Rupture of membranes can lead to changes in amniotic fluid, which can affect the fetal environment and potentially cause fetal distress. By assessing the fetal heart rate pattern, the nurse can determine if the baby is tolerating the labor process well or if there are signs of fetal compromise that require further intervention.

Choice A rationale:

While assessing the client's blood pressure (Choice A) is important during labor, it is not the immediate next action when the membranes have ruptured.

Choice C rationale:

Taking the client's temperature (Choice C) is also important, but it is not the priority action when the membranes have ruptured.

Choice D rationale:

Preparing for a c-section (Choice D) is not the initial action unless there are specific indications for an emergency cesarean section. Assessing the fetal heart rate is more critical at this stage.

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Correct Answer is C

Explanation

Choice A rationale:

Monitoring fluid intake is important for any newborn, but it is not the priority intervention for a small for gestational age (SGA) newborn. SGA infants are at risk of hypoglycemia due to limited glycogen stores, and monitoring blood glucose levels is crucial in identifying and managing hypoglycemia.

Choice B rationale:

Monitoring axillary temperature is essential for all newborns to assess their thermoregulation. However, it is not the priority intervention for an SGA newborn. Hypoglycemia is a more immediate concern and must be addressed promptly.

Choice C rationale:

Monitoring blood glucose levels is the priority intervention for an SGA newborn. As mentioned earlier, SGA infants are at higher risk of hypoglycemia, which can lead to serious complications if not managed appropriately. By monitoring blood glucose levels, the nurse can detect and address hypoglycemia early.

Choice D rationale:

Monitoring weight is important for tracking the growth and development of the newborn, but it is not the priority intervention in this scenario. The immediate concern for an SGA newborn is their blood glucose levels.

A. Edema. B. BP 155/92. C. Proteinuria. D. Hepatic dysfunction. E. BP returns to normal after pregnancy.

Correct Answer is ["B","C"]

Explanation

Choice A rationale:

Edema is not an expected finding of uncomplicated gestational hypertension. While some degree of edema can be common during pregnancy, it is not specifically related to gestational hypertension.

Choice B rationale:

A blood pressure reading of 155/92 is an expected finding in a client with uncomplicated gestational hypertension. Gestational hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg after 20 weeks of pregnancy, without the presence of proteinuria or other organ dysfunction.

Choice C rationale:

Proteinuria is an expected finding in gestational hypertension. It is an important diagnostic criterion for preeclampsia, which is a severe form of gestational hypertension.

Choice D rationale:

Hepatic dysfunction is not an expected finding in uncomplicated gestational hypertension. Hepatic dysfunction would indicate more severe complications such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count), which is a medical emergency.

Choice E rationale:

Blood pressure usually returns to normal after pregnancy in women with uncomplicated gestational hypertension. However, it is essential to monitor the client closely postpartum to ensure blood pressure normalization.

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A laboring client's membranes have just ruptured. What is the nurse's next action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a newborn who is small for gestational age (SGA) Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Correct Answer is C

Explanation

The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

Correct Answer is ["B","C"]

Explanation

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