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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Correct Answer is ["A","D","E"]

Explanation

A. Labor induction with oxytocin increases the risk for uterine atony due to prolonged stimulation of uterine muscles, which predisposes the client to postpartum hemorrhage.
B. A newborn weight of 2.948 kg (6 lb 8 oz) is within normal range and does not increase the risk for postpartum hemorrhage.
C. A history of human papillomavirus (HPV) does not contribute to postpartum hemorrhage risk.
D. A history of uterine atony places the client at high risk for postpartum hemorrhage, as the uterus may fail to contract effectively after delivery.
E. Vacuum-assisted delivery increases the risk of trauma and retained placental fragments, both of which can lead to postpartum hemorrhage.

A. "I should place the car seat rear-facing until my baby is 12 months old." B. "I should position the retainer clip at the top of my baby's abdomen." C. "I should position my baby's car seat at a 45" angle in the car D. "I should place the harness snugly in a slot above my baby's shoulders."

Correct Answer is C

Explanation

A. The car seat should remain rear-facing until at least age 2, or until the child reaches the maximum height and weight limit specified by the manufacturer, not just until 12 months.
B. The retainer (chest) clip should be positioned at the level of the infant's armpits, not the abdomen, to ensure proper restraint.
C. Positioning the car seat at a 45° angle helps keep the infant’s airway open and reduces the risk of aspiration or airway obstruction.
D. For rear-facing seats, the harness straps should be at or below the baby's shoulders, not above.

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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 is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is providing discharge teaching to a new guardian about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

Correct Answer is C

Explanation

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