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

This is based on the fact that HIV is a virus that attacks the body’s immune system and is spread through certain body fluids, including breast milk.Perinatal transmission can occur during pregnancy, birth, or breastfeeding.Treatment for HIV (antiretroviral therapy, or ART) substantially reduces the risk of perinatal transmission.

Choice A is wrong because sterilizing breast milk does not kill the HIV virus.

Choice B is wrong because colostrum can also contain the HIV virus and testing it is not feasible or reliable.

Choice C is wrong because breastfeeding may still pose a risk of HIV transmission even if the infant is determined to be HIV positive.

The current recommendation in the United States supports shared decision-making between mothers and their healthcare providers regarding infant feeding.Mothers who have questions about breastfeeding or who want to breastfeed should receive patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.

Counseling should begin before conception, or as early as possible in pregnancy and should be

A. The time and amount of the first post-procedure voiding. B. The erectile ability of the penis. C. The position of the urethral opening on the penis. D. The presence of a small amount of white-yellow exudate around the glans tissue.

Correct Answer is A

Explanation

This is because circumcision is a surgical procedure that involves cutting off the foreskin of the penis, which may affect the urinary function of the baby.The nurse should make sure that the baby can urinate normally and without pain after the circumcision.

The amount of urine should be adequate for the baby’s weight and hydration status.

Choice B is wrong because the erectile ability of the penis is not affected by circumcision and is not a priority for discharge planning.

Choice C is wrong because the position of the urethral opening on the penis is not related to circumcision and should be assessed at birth, not at discharge.

Choice D is wrong because the presence of a small amount of white-yellow exudate around the glans tissue is normal and expected after circumcision.It is part of the healing process and does not indicate infection.The nurse should instruct the parents on how to care for the circumcised penis and when to seek medical attention if there are signs of complications.

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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

A mother of a 3-hour-old infant requests information concerning breastfeeding. The mother has tested positive for human immunodeficiency virus (HIV).A nurse’s response should be based on which fact?

Correct Answer is D

Explanation

A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

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?