A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital.”. Which of the following actions should the nurse take first?
Ask the client about the color of the fluid.
Determine the fetal heart rate.
Monitor cervical dilation.
Obtain the client's vaginal pH.
The Correct Answer is B
Choice A rationale
Asking about the fluid's color (clear, meconium-stained, bloody) provides information about fetal well-being and potential complications (like meconium aspiration), but it is a secondary assessment. While important, it does not supersede the need to immediately assess the most urgent physiological parameter of fetal status, which is the heart rate.
Choice B rationale
The rupture of membranes (water breaking) carries a risk of prolapsed umbilical cord, which can severely compromise fetal oxygenation by compressing the umbilical vessels. Determining the fetal heart rate (FHR) immediately is the priority action to identify signs of fetal distress, such as bradycardia (FHR <110 beats/min), indicating cord compression. The normal FHR range is 110-160 beats/min.
Choice C rationale
Monitoring cervical dilation is necessary to determine the stage and progress of labor. However, in the setting of ruptured membranes, assessing the immediate safety and stability of the fetus takes precedence over checking labor progress. A vaginal exam to check dilation is done after assessing FHR and ruling out immediate emergencies like cord prolapse.
Choice D rationale
Determining the vaginal pH with Nitrazine paper can confirm if the fluid is amniotic fluid (alkaline, pH 7.0-7.5) or urine/vaginal secretions (acidic). While this confirms the rupture of membranes, establishing the status of the fetus by assessing the FHR is the most critical and life-saving priority action to take first to prevent or quickly address fetal hypoxia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Step 1 is: Start with the first day of the last menstrual period (LMP): July 21st.
Step 2 is: Subtract 3 months: July minus 3 months is April.
Step 3 is: Add 7 days to the LMP day: 21 plus 7 days is the 28th.
Step 4 is: Add 1 year: April 28th of the following year. Final calculated answer: April 28th.
Correct Answer is C
Explanation
Choice A rationale
Although antiviral medications such as acyclovir or valacyclovir can suppress viral replication and reduce the frequency, duration, and severity of outbreaks, they do not eliminate the virus from the body. Genital herpes simplex virus (HSV-2) infection is a chronic, lifelong condition for which there is currently no known cure, therefore, medication will only manage the symptoms.
Choice B rationale
Genital herpes simplex virus (HSV-2) can be transmitted vertically from mother to fetus or newborn, particularly during a primary infection in pregnancy or during vaginal birth. Neonatal herpes infection can be severe or fatal, causing disseminated disease, central nervous system involvement, or mucocutaneous lesions, thus, it is a significant risk to the developing fetus/newborn.
Choice C rationale
The risk of neonatal transmission of HSV-2 is significantly higher (around 25.
Choice D rationale
Wearing tight-fitting undergarments can increase heat and moisture in the genital area, leading to friction and irritation of the lesions, which can prolong healing and increase discomfort during an outbreak. Clients are advised to wear loose-fitting cotton undergarments to keep the area dry and promote air circulation, which helps with lesion healing.
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