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 B
Explanation
The correct answer is choice B. Syphilis.A negative rapid plasma reagin (RPR) test indicates that a patient is probably not infected with syphilis, a sexually transmitted infection (STI) caused by the bacterium Treponema pallidum.The RPR test works by detecting the nonspecific antibodies that your body produces while fighting the infection.
Choice A is wrong because herpes simplex II is a viral infection that causes genital herpes, and it is not detected by the RPR test.
Choice C is wrong because gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae, and it is also not detected by the RPR test.
Choice D is wrong because condylomata are genital warts caused by human papillomavirus (HPV), and they are not detected by the RPR test either.
The RPR test is a screening test, and it can give false-positive results due to other conditions or infections.Therefore, a positive RPR test should always be confirmed by a more specific treponemal test, such as TPPA or FTA-ABS.The RPR test can also be used to monitor the treatment response of syphilis, as the antibody levels should decrease after effective antibiotic therapy.
Correct Answer is A
Explanation
The correct answer is choice C. Caloric intake should be 300 calories above the suggested non-pregnant caloric intake.This is because women with gestational diabetes need to meet the nutritional needs of pregnancy and also control their blood glucose levels.
Choice A is wrong because carbohydrates should make up about 45% of the total dietary intake for women with gestational diabetes, not 25%.
Carbohydrates are important for providing energy and nutrients for the mother and the baby.
Choice B is wrong because animal protein can be included in the pre-bedtime snack as long as it is combined with some carbohydrates.
Protein can help prevent low blood glucose levels during the night.
Choice D is wrong because sugar substitutes do not help to control blood glucose levels.They may also have adverse effects on the baby’s development.Women with gestational diabetes should limit their intake of added sugars and choose foods with natural sugars instead.
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