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 D

Explanation

The correct answer is choice D: “This test is used to identify fetal abnormalities.” Alpha-fetoprotein (AFP) is a protein produced by the fetus that can be measured in the mother’s blood.

Abnormal levels of AFP may indicate a problem with the development of the baby’s brain, spine, or other organs.

This test is usually done between 15 and 20 weeks of gestation.

Choice A is wrong because AFP does not measure the baby’s maturity.

It is not related to the gestational age or the lung development of the fetus.

Choice B is wrong because AFP is not a routine test for all pregnant women over thirty years of age.

It is an optional screening test that may be offered to women who have a higher risk of having a baby with a birth defect, such as those who have a family history, a previous affected pregnancy, or certain ethnic backgrounds.

Choice C is wrong because AFP is not recommended for people with a history of infertility.

It does not assess the fertility status of the mother or the father.

It only measures the level of a fetal protein in the mother’s blood.

A. A 23-year-old primigravida with a history of endometriosis. B. A 40-year-old multigravida with a history of condyloma acuminata. C. A 27-year-old primigravida with a bicornuate uterus. D. A 36-year-old multigravida who has had two previous cesarean deliveries.

Correct Answer is A

Explanation

The correct answer is choice A. A 23-year-old primigravida with a history of endometriosis.Endometriosis is a condition where the tissue that normally lines the uterus grows outside of it, sometimes affecting the fallopian tubes.This can cause scarring and damage to the tubes, which can increase the risk of ectopic pregnancy.

Choice B is wrong because condyloma acuminata, also known as genital warts, are caused by human papillomavirus (HPV) infection.HPV infection does not directly increase the risk of ectopic pregnancy, although it may be associated with other sexually transmitted infections (STIs) that can cause pelvic inflammatory disease (PID), which is a risk factor.

Choice C is wrong because a bicornuate uterus is a congenital anomaly where the uterus has two horns or chambers instead of one.This does not affect the fallopian tubes or the implantation of the fertilized egg in the uterus.

Choice D is wrong because previous cesarean deliveries do not increase the risk of ectopic pregnancy.However, previous tubal surgery, such as tubal ligation or salpingectomy, can damage the fallopian tubes and increase the risk.

Other risk factors for ectopic pregnancy include previous ectopic pregnancy, smoking, age older than 35 years, history of infertility, and use of assisted reproductive technology.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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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?