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:

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. Request a prescription for PRN aspirin from the provider. B. Massage the injection site thoroughly following administration. C. Instruct the client that they cannot breastfeed while receiving heparin. D. Administer the injection in the client's abdomen.

Correct Answer is D

Explanation

Choice A reason:

Requesting a prescription for PRN aspirin is incorrect because aspirin is an antiplatelet agent and should not be combined with heparin without specific medical advice due to the increased risk of bleeding.

Choice B reason:

Massaging the injection site is not recommended as it can cause trauma to the tissue and increase the risk of bleeding, which is especially concerning in a patient with deep-vein thrombosis.

Choice C reason:

Instructing the client that they cannot breastfeed while receiving heparin is incorrect. Heparin does not pass into breast milk in significant amounts and is considered safe for use while breastfeeding.

Choice D reason:

Administer the injection in the client's abdomen. Heparin is typically administered subcutaneously in the abdomen to ensure proper absorption and minimize discomfort. Because it is an area with large amounts of subcutaneous fat

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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 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 postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?

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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.)

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

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?

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 in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?