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

The correct answer is choice C. The reason for the patient’s visit at this time.

This information will help the nurse assess the patient’s motivation, readiness, and urgency for contraception.

It will also help the nurse tailor the education and counseling to the patient’s specific needs and preferences.

Choice A is wrong because the amount of sexual experience that the patient has had is not relevant to determine the patient’s knowledge base.

It may also make the patient feel uncomfortable or judged.

Choice B is wrong because the type of contraceptive that the patient’s friends are using is not a reliable source of information.

Different methods may have different advantages and disadvantages for different people.

The nurse should provide evidence-based information and guidance on various options.

Choice D is wrong because the method of contraception that the patient believes will provide protection from sexually transmitted diseases may not be accurate or effective.

The correct answer is choice C. Dryness and flaking of the skin on the hands and feet.This is because a newborn with a gestational age of 42 weeks is considered post-mature and has lost the protective vernix caseosa that covers the skin of most newborns.The skin of a post-mature newborn is also more exposed to the amniotic fluid, which can cause it to peel and crack.

Choice A is wrong because sole creases that cover only the anterior one-third of the foot are characteristic of a preterm newborn, not a post-mature one.

Choice B is wrong because vernix caseosa is abundant in preterm newborns and decreases as gestational age increases.A post-mature newborn would have little or no vernix caseosa on the skin.

Choice D is wrong because a large amount of fine, downy hair (lanugo) on the back and shoulders is also typical of a preterm newborn, not a post-mature one.Lanugo usually disappears by 36 weeks of gestation.A post-mature newborn would have little or no lanugo on the body.