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 A

Explanation

Choice A rationale:

The nurse should plan to administer Ampicillin to the client with a group B streptococcus (GBS) B-hemolytic infection. Ampicillin is the first-line antibiotic treatment for intrapartum prophylaxis in GBS-positive pregnant women. It helps prevent the transmission of the bacteria from the mother to the newborn, reducing the risk of early-onset GBS infection in the infant.

Choice B rationale:

Azithromycin is not the appropriate choice for treating GBS B-hemolytic infection during labor. While Azithromycin is effective against certain bacteria, it is not the recommended antibiotic for GBS prophylaxis in labor. Ampicillin or Penicillin is the preferred medication in this scenario.

Choice C rationale:

Ceftriaxone is not the appropriate medication for treating GBS B-hemolytic infection during labor. Ceftriaxone belongs to the cephalosporin class of antibiotics and is not the first-line treatment for GBS prophylaxis. Ampicillin or Penicillin is the preferred choice.

Choice D rationale:

Acyclovir is an antiviral medication and is not indicated for the treatment of GBS B-hemolytic infection. GBS is a bacterial infection, and antiviral medications like Acyclovir do not have an effect on bacteria.

A. WBC count 11,000/mm³. B. Hgb 11.2 g/dL. C. Hct 34%. D. Platelets 140,000/mm³.

Correct Answer is D

Explanation

Choice A rationale:

The normal WBC count during pregnancy can vary, but a count of 11,000/mm³ is within an acceptable range. During pregnancy, the WBC count can be slightly elevated due to physiological changes in the body to support the growing fetus.

Choice B rationale:

The normal hemoglobin level during pregnancy is generally around 11 to 12.5 g/dL. Therefore, a hemoglobin level of 11.2 g/dL falls within the normal range, and the nurse does not need to report this finding.

Choice C rationale:

The normal hematocrit (Hct) during pregnancy can vary, but a level of 34% is within the acceptable range. Hct levels can be lower during pregnancy due to increased plasma volume, leading to a mild physiological anemia of pregnancy.

Choice D rationale:

The normal platelet count during pregnancy is typically around 150,000 to 400,000/mm³. With a platelet count of 140,000/mm³, this is slightly below the lower end of the normal range. Thrombocytopenia during pregnancy can increase the risk of bleeding, both during childbirth and postpartum, so the nurse should report this finding to the provider for further evaluation and management.

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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 client who is in labor and has a diagnosis of group B streptococcus B- hemolytic infection. Which of the following medications should the nurse plan to administer?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

Correct Answer is D

Explanation

The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

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A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

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A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?