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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Digoxin is a cardiac glycoside and is primarily used in the management of certain heart conditions, such as heart failure and atrial fibrillation. It is not indicated for hyperemesis gravidarum, which is severe and persistent vomiting during pregnancy.
Choice B rationale:
Calcium gluconate is a mineral supplement used to treat calcium deficiencies. It is not a standard treatment for hyperemesis gravidarum.
Choice C rationale:
Vitamin Bs (B6 and B12) are commonly used to manage hyperemesis gravidarum. Vitamin B6, also known as pyridoxine, has been shown to alleviate nausea and vomiting during pregnancy. Vitamin B12 may also be administered to help manage symptoms. Both vitamins are safe to use during pregnancy.
Choice D rationale:
Propranolol is a beta-blocker used to treat high blood pressure, heart conditions, and migraines. It is not recommended for managing hyperemesis gravidarum and is generally avoided during pregnancy due to potential risks to the developing fetus.
Correct Answer is C
Explanation
A. Vitamin E is important for overall health but does not need to be specifically increased during pregnancy.
B. Vitamin D supports calcium absorption, but routine intake is generally sufficient unless a deficiency exists.
C. Fiber intake should be increased during pregnancy to help prevent constipation, which is a common issue due to hormonal changes and slowed gastrointestinal motility.
D. Calcium intake is important, but for many clients, standard dietary recommendations are adequate unless otherwise prescribed.
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