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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Keeping the newborn dressed while receiving phototherapy is not recommended because the baby's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Direct exposure to light helps break down the excess bilirubin in the baby's blood, leading to its excretion.

Choice B rationale:

Applying lotion to the skin twice daily is contraindicated during phototherapy. Lotions and creams can block the light from reaching the skin and hinder the therapeutic effects of the phototherapy. The baby's skin should remain exposed to the light for optimal treatment.

Choice C rationale:

Maintaining an eye mask over the newborn's eyes is essential during phototherapy. The eyes are sensitive to light, and prolonged exposure to the phototherapy light can lead to eye damage. Using an eye mask protects the baby's eyes while allowing the rest of the body to receive the necessary light treatment.

Choice D rationale:

Maintaining the phototherapy during blood draws is crucial to ensure continuous treatment of hyperbilirubinemia. Interrupting the phototherapy during blood draws might result in the rebound of bilirubin levels, which can be harmful to the baby.

A. Assist the client to void every 3 hr. B. Monitor contractions every 30 min. C. Place the client into a lithotomy position. D. Encourage the client to use a pant-blow breathing pattern.

Correct Answer is D

Explanation

Choice D rationale:

During the transition phase of labor, the nurse should encourage the client to use a pant- blow breathing pattern. The transition phase is intense, and pant-blow breathing (a form of controlled breathing) can help the client manage the pain and reduce anxiety. Panting during contractions allows the client to focus on short, shallow breaths, which can be more effective than deep breathing during this stage.

Choice A rationale:

Assisting the client to void every 3 hours is important during labor, but it is not specific to the transition phase. The nurse should encourage the client to void regularly during the entire labor process to prevent bladder distension and facilitate the descent of the baby. However, during the transition phase, the client may be more focused on contractions and may not need reminders to void every 3 hours.

Choice B rationale:

Monitoring contractions every 30 minutes is not appropriate during the transition phase of labor. The transition phase is characterized by frequent and strong contractions, and continuous monitoring of contractions is usually required during this phase to ensure fetal well-being and progress in labor.

Choice C rationale:

Placing the client into a lithotomy position is not appropriate during the transition phase of labor. The lithotomy position, where the client lies on their back with legs raised and supported in stirrups, is often used during the pushing phase. During the transition phase, it is more common for the client to be in an upright or semi-reclining position to facilitate the descent of the baby through the birth canal.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is C

Explanation

A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching?

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

A nurse is providing teaching to a client who is at 32 weeks of gestation and is experiencing stress incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?

A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?

A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?