A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously.
Which action should the nurse take next?

Check the specific gravity of the amniotic fluid.

Provide dry linens for the patient.

Auscultate the fetal heart sounds.

Notify the health care provider.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Auscultate the fetal heart sounds. This is because spontaneous rupture of membranes (SROM) may be associated with fetal distress or cord prolapse, and the nurse should assess the fetal well-being as soon as possible. Fetal heart sounds can indicate the presence of fetal bradycardia, tachycardia, or decelerations, which may require immediate intervention.

Choice A is wrong because checking the specific gravity of the amniotic fluid is not a priority action after SROM. The specific gravity can help differentiate amniotic fluid from urine, but it is not as reliable as other methods such as nitrazine paper test or visual inspection.

Choice B is wrong because providing dry linens for the patient is a comfort measure, but not a priority action after SROM. The nurse should first ensure the safety of the fetus and the mother before attending to their comfort needs.

Choice D is wrong because notifying the health care provider is an important action after SROM, but not the first one. The nurse should gather relevant data such as fetal heart rate, maternal vital signs, and characteristics of the fluid before contacting the provider.

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Correct Answer is C

Explanation

The correct answer is choice C. Caloric intake should be 300 calories above the suggested non-pregnant caloric intake.This is because women with gestational diabetes need to meet the nutritional needs of pregnancy and also control their blood glucose levels.

Choice A is wrong because carbohydrates should make up about 45% of the total dietary intake for women with gestational diabetes, not 25%.

Carbohydrates are important for providing energy and nutrients for the mother and the baby.

Choice B is wrong because animal protein can be included in the pre-bedtime snack as long as it is combined with some carbohydrates.

Protein can help prevent low blood glucose levels during the night.

Choice D is wrong because sugar substitutes do not help to control blood glucose levels.They may also have adverse effects on the baby’s development.Women with gestational diabetes should limit their intake of added sugars and choose foods with natural sugars instead.

A. “I should expect a few spots of blood on my underwear because I have more blood in my body now.”. B. “Clear fluid will leak from my vagina if my baby is surrounded by too much water in my womb.”. C. “If I begin to see dark patches on my face, it means that my blood pressure is rising.”. D. “If I feel like I have butterflies in my stomach, it means my baby is moving.”.

Correct Answer is D

Explanation

The correct answer is choice D. If the client feels like she has butterflies in her stomach, it means her baby is moving.

This is a normal and expected change during pregnancy, especially in the second and third trimesters.The baby’s movements can be felt as flutters, kicks, or rolls.

Choice A is wrong because spotting of blood on the underwear is not a normal change during pregnancy.

It can indicate a problem such as placenta previa, placental abruption, or miscarriage.Any bleeding during pregnancy should be reported to the health care provider.

Choice B is wrong because clear fluid leaking from the vagina is not a normal change during pregnancy.

It can indicate that the membranes have ruptured and amniotic fluid is escaping.

This can lead to infection and preterm labor if not treated promptly.Any fluid leakage during pregnancy should be reported to the health care provider.

Choice C is wrong because dark patches on the face are not a sign of high blood pressure during pregnancy.

They are called melasma or chloasma and are caused by increased pigmentation due to hormonal changes.They usually fade after delivery and are not harmful.High blood pressure during pregnancy can cause symptoms such as headache, blurred vision, swelling, and protein in the urine.

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A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously. Which action should the nurse take next?

Nursing Test Bank

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Correct Answer is D

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A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously.
Which action should the nurse take next?