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 D
Explanation
Choice A rationale:
Having many nodules in the upper outer quadrants of the breasts is a common and expected finding in breast tissue and is not necessarily a cause for concern.
Choice B rationale:
Bilateral breast tenderness with palpation can be a normal finding, especially in young women with hormonal changes. It is not of immediate concern unless it is accompanied by other worrisome symptoms.
Choice C rationale:
Slight differences in breast size are often normal and not necessarily concerning, especially in young women whose breast development may not have fully stabilized.
Choice D rationale:
An irregularly shaped, nontender lump palpable in the breast raises concerns for a potential breast mass or tumor. This finding requires further evaluation and investigation by a healthcare provider to determine its nature and possible malignancy. Early detection of breast abnormalities is crucial for timely management and improved outcomes.
Correct Answer is C
Explanation
The correct answer is choice C: "I will tip the nipple so air is present as my baby sucks.”
Choice A rationale:
The parent's statement in choice A, "I will keep my baby's head elevated while he is feeding,” indicates an understanding of proper bottle feeding techniques. Keeping the baby's head slightly elevated can help prevent choking and aspiration during feedings. This is a correct statement, and no further instruction is needed in this regard.
Choice B rationale:
The parent's statement in choice B, "I will allow my baby to burp several times during each feeding,” also demonstrates knowledge of appropriate bottle feeding practices. Burping the baby during and after feedings helps release swallowed air, reducing the likelihood of excessive gas and discomfort. This statement is correct, and no additional instruction is required.
Choice C rationale:
Choice C is the incorrect statement because tipping the nipple to introduce air while the baby sucks is not a recommended practice. In fact, it can lead to an increased intake of air, potentially causing gas, discomfort, and colic in the baby. Therefore, further instruction is needed to correct this misconception.
Choice D Rationale:
Choice D is not directly related to the need for further instruction in bottle feeding techniques and is not addressed in the explanation.
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