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 A
Explanation
Choice A rationale:
Petroleum jelly is a common recommendation to apply during diaper changes for circumcised newborns. It acts as a barrier between the diaper and the healing penis, reducing friction and preventing the diaper from sticking to the sensitive area. This can help promote better healing and prevent discomfort for the newborn.
Choice B rationale:
Pre-moistened towelettes are not typically recommended for application on the penis of a circumcised newborn during diaper changes. These towelettes may contain chemicals or irritants that could potentially irritate the delicate skin of the healing area.
Choice C rationale:
Povidone-iodine is an antiseptic solution often used to disinfect the skin before procedures or surgeries. However, it is not recommended for routine use on the penis of a circumcised newborn during diaper changes as it may be too harsh for the healing skin.
Choice D rationale:
Silver sulfadiazine is a topical antimicrobial agent used for treating burns and certain infections. However, it is not indicated for use on a circumcised newborn's penis during diaper changes. The healing process after circumcision does not usually involve infections that require this type of treatment.
Correct Answer is A
Explanation
Choice A rationale:
When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.
Choice B rationale:
Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.
Choice C rationale:
Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.
Choice D rationale:
Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.
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