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 B

Explanation

A. An indwelling urinary catheter is typically inserted before surgery, not immediately after, to keep the bladder empty during the procedure.
B. Applying sequential compression devices prior to the procedure is a key intervention to prevent deep vein thrombosis, which is a high-risk complication for clients undergoing cesarean birth.
C. Performing a surgical timeout is important but is a standard surgical protocol rather than a nursing-specific intervention for cesarean birth preparation.
D. Oxytocin is administered after delivery of the placenta to promote uterine contraction and prevent postpartum hemorrhage, not before surgery.

A. "Remove your newborn's electronic monitoring band for bathing." B. “Limit visitors to your immediate family.” C. "Send the newborn to the nursery while you are sleeping - D. Check identification badges of staff who enter your room

Correct Answer is D

Explanation

A. The electronic monitoring band should remain on the newborn at all times to ensure security.
B. While visitor limitations may be advised during outbreaks or pandemics, this is not a standard newborn security measure.
C. Sending the newborn to the nursery unsupervised increases the risk of abduction and is not recommended.
D. Parents should be encouraged to verify staff identification to enhance newborn security and safety.

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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 planning care for a client who is scheduled for a cesarean birth. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is providing information about newborn security to the parents of a newborn. Which of the following instructions should the nurse provide?

Correct Answer is D

Explanation

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