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. The woman’s temperature will increase when she is ovulating.This is because ovulation is triggered by a surge of luteinizing hormone (LH), which also causes a slight rise in basal body temperature (BBT).By measuring her BBT every morning before getting out of bed, the woman can detect this subtle change and identify her fertile window.

Choice A is wrong because ovulation typically occurs around 14 days before the next menstrual period, not seven days after the previous one.

The length of the menstrual cycle can vary from woman to woman, so counting days is not a reliable method of predicting ovulation.

Choice B is wrong because cervical mucus will appear clear, slippery and stretchy when the woman is ovulating, not tacky and cloudy.

This type of mucus helps sperm swim and survive in the reproductive tract.

The woman can check her cervical mucus by wiping with toilet paper or inserting a finger into her vagina.

Choice D is wrong because abdominal massage of the ovaries will not stimulate ovulation, and may even cause harm by injuring the delicate tissues or introducing infection.

A. They need less supplemental iron than women who have been menstruating longer because their reserves are generally greater. B. They have less need for simple carbohydrates than older women because they are able to convert fat stores into usable glucose. C. Their need for protein exceeds that of pregnant women over 20 years of age. D. Their need for vitamin C is greater than that of pregnant women over 20 years of age.

Correct Answer is C

Explanation

The correct answer is choice C.Adolescents need more protein than older pregnant women because they are still growing themselves and need to support the growth of the baby and the placenta.Protein can be found in meat, poultry, fish, eggs, dairy products, beans, nuts, and fortified cereals.

Choice A is wrong because adolescents need more supplemental iron than older women, not less.This is because they have lower iron stores due to rapid growth and menstruation.Iron deficiency can cause anemia and increase the risk of infections and bleeding.Iron can be found in meat, poultry, fish, eggs, dairy products, beans, nuts, and fortified cereals.

Choice B is wrong because adolescents need more carbohydrates than older women, not less.Carbohydrates provide energy for the mother and the baby and spare protein for other functions.Carbohydrates can be found in grains, fruits, vegetables, and dairy products.

Choice D is wrong because adolescents need the same amount of vitamin C as older pregnant women, which is 85 milligrams per day.Vitamin C helps with wound healing, collagen formation, iron absorption, and immune function.Vitamin C can be found in citrus fruits, tomatoes, peppers, broccoli, potatoes, and fortified juices.

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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?