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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}

Explanation

Administer an iron supplement: The client has low hemoglobin, hematocrit, RBCs, and ferritin, which are consistent with iron deficiency anemia. Iron supplementation is expected to help correct the deficiency and improve oxygen-carrying capacity.
Refer for a nutritional consult: A vegan diet, if not properly planned, can lack adequate sources of iron and vitamin B12. A nutritionist can help the client meet dietary needs through fortified foods or supplements, addressing underlying causes of anemia.

Place the client on a low sodium diet: The client’s blood pressure is within acceptable range, and there is no history of hypertension or fluid overload. A low sodium diet would not target the client’s current symptoms of anemia and fatigue.
Restrict fluid intake: The client shows signs of volume depletion (orthostatic hypotension and low Hct) rather than fluid overload. Restricting fluids could worsen hypotension and contribute to decreased perfusion, making it inappropriate.

A. Insert an indwelling urinary catheter. B. Evaluate deep tendon reflexes. C. Determine motor function of lower extremities. D. Administer meperidine hydrochloride IV.

Correct Answer is C

Explanation

A. Catheterization may be necessary if the client cannot void but is not the first step before ambulation.
B. Evaluating deep tendon reflexes is more relevant for clients receiving magnesium sulfate, not primarily for epidural assessment.
C. Assessing motor function of the lower extremities ensures the client has adequate strength and sensation to safely ambulate after an epidural.
D. Administering meperidine is for pain management and does not relate to safety before ambulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}

Explanation

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Correct Answer is C

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