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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: To prevent her from having convulsions.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy.Magnesium sulfate can lower the cerebral perfusion pressure and prevent convulsions.However, magnesium sulfate does not affect the neonatal outcomes and can cause side effects such as respiratory depression.
Choice A is wrong because magnesium sulfate does not decrease blood pressure.It is used along with medications that help reduce blood pressure.
Choice B is wrong because magnesium sulfate does not decrease tidal volume.It can cause respiratory depression if the serum level is too high.
Choice C is wrong because magnesium sulfate does not prevent dehydration.It can cause fluid retention and pulmonary edema if given in excess.
Correct Answer is A
Explanation
The correct answer is choice A. The patient uses the sitz bath three times a day.This indicates that the patient understands the benefits of sitz baths for postpartum recovery, such as pain relief, increased blood flow, relaxation, cleansing, and itch relief.Sitz baths can be done with warm or cool water, depending on the preference of the patient.However, they should not be done for more than 20 minutes at a time, as this can cause the stitches in the perineal area to fall apart.
Therefore, choice C is wrong.Choice B is also wrong, as there is no evidence that alternating between warm and cool sitz baths has any additional benefits or effects.
Choice D is wrong, as tightening and relaxing the perineal muscles during a sitz bath is not recommended.This can cause more pain and irritation to the area, and interfere with the healing process.The normal ranges for sitz baths are two to four times a day for up to 20 minutes each.
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