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?
Monitor cervical dilation.
Ask the client about the color of the water.
Obtain the client's vaginal pH.
Determine the fetal heart rate.
The Correct Answer is D
A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. High-pitched, excessive crying is a common sign of neonatal abstinence syndrome (NAS).
B. Tachypnea (rapid breathing) is a typical respiratory symptom of NAS.
C. Body tremors and jitteriness are classic signs of withdrawal in newborns.
D. Newborns with NAS typically exhibit hyperactivity, not extreme lethargy.
E. Reflexes are usually increased (hyperactive), not decreased, in NAS.
Correct Answer is B
Explanation
A. A transvaginal fetal Doppler is not commonly used for continuous monitoring and is typically reserved for early pregnancy.
B. An external ultrasound transducer is appropriate for continuous fetal monitoring when the membranes are intact. It is noninvasive and safe for use during labor.
C. A DeLee Hillis fetoscope is used for intermittent auscultation, not continuous monitoring.
D. An internal fetal scalp electrode requires ruptured membranes and cervical dilation; it is contraindicated with intact membranes.
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