A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?
Perform another internal exam.
Notify the client's provider.
Check the FHR.
Obtain a pH test of the fluid.
The Correct Answer is C
A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.
B. Notifying the client's provider may be necessary, but it is not the immediate priority.
C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.
D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wearing an underwire bra between feedings can compress the breasts and potentially lead to mastitis. Nursing bras without underwire are recommended.
B. Covering the breasts immediately after feedings can trap moisture and promote bacterial growth, increasing the risk of mastitis.
C. Cold compresses can help relieve discomfort from engorgement, but applying them before feedings may hinder milk flow and emptying of the breasts, which could increase the risk of mastitis.
D. Ensuring the baby fully empties the breasts with each feeding helps prevent engorgement and decreases the risk of mastitis by promoting effective milk removal.
Correct Answer is C
Explanation
A. Varenicline is a medication used for smoking cessation, not for treating gambling disorder.
B. Disulfiram is a medication used to discourage alcohol consumption by inducing unpleasant side effects if alcohol is consumed; it is not used for treating gambling disorder.
C. Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant that has been shown to be effective in treating gambling disorder by reducing gambling urges and behaviors.
D. Clonidine is an alpha-2 adrenergic agonist used to treat conditions such as hypertension and attention deficit hyperactivity disorder (ADHD); it is not typically used for treating gambling disorder.
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