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 B

Explanation

Choice A rationale:

Multiparity, or having given birth to multiple children, is associated with a decreased risk of ovarian cancer, not an increased risk. The protective effect may be due to the repeated ovulatory cycles that occur during pregnancy.

Choice B rationale:

Endometriosis is a condition where endometrial tissue grows outside the uterus. It is associated with an increased risk of ovarian cancer. The exact link is not fully understood, but it is believed that the inflammatory and hormonal changes in endometriosis may contribute to cancer development.

Choice C rationale:

Being under 40 years of age does not increase the risk of ovarian cancer. Advanced age is a known risk factor for ovarian cancer, with the highest incidence occurring in women over 60.

Choice D rationale:

Use of contraceptive medications, particularly oral contraceptives, has been shown to reduce the risk of ovarian cancer. These medications suppress ovulation and decrease the exposure of the ovaries to potential carcinogens.

A. Check the newborn's temperature every 8 hr. B. Apply moisturizing lotion to the newborn's skin every 4 hr. C. Give the newborn 1 oz of glucose water every 4 hr. D. Reposition the newborn every 2 to 3 hr.

Correct Answer is D

Explanation

Choice A rationale:

Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.

Choice B rationale:

Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.

Choice C rationale:

Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition.

Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.

Choice D rationale:

Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.

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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

Which of the following would increase a client's risk of ovarian cancer?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?

A nurse is caring for a client who has placenta previa. Which of the following interventions should the nurse implement for this client? (Select all that apply.)

A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?

A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?

A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?