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 C
Explanation
The correct answer is choice C. Arrange for her to meet the staff who will be caring for her during labor and delivery.This measure can help reduce the anxiety and fear of the unknown that a primigravida may have in the last month of pregnancy.Meeting the staff can also help establish rapport and trust, which are essential for a positive birth experience.
Choice A is wrong because an increase in fetal activity does not necessarily require an increase in the need to rest.
Fetal activity is normal and expected, and the mother should monitor it regularly.Resting may help with some discomforts of pregnancy, but it is not directly related to fetal activity.
Choice B is wrong because back labor is not likely for a primigravida with an uncomplicated pregnancy.
Back labor occurs when the fetus is in an occiput posterior position, which puts pressure on the mother’s spine and causes intense pain in the lower back.This position is more common in multiparous women than primigravidas.
Choice D is wrong because testing urine for glucose is not a routine measure for a primigravida with an uncomplicated pregnancy.
Urine glucose testing is done for women who have gestational diabetes or are at risk of developing it.It is not necessary for women who have normal blood glucose levels.
Correct Answer is A
Explanation
he correct answer is choice A. “Instead of having eggs, I am eating yogurt for breakfast.” This statement shows a need for further instruction because eggs are a good source of protein and yogurt is not.
Yogurt is a dairy product that contains mostly carbohydrates and some fat.
Eggs are an animal product that contains mostly protein and some fat.
Protein is important for building and repairing tissues in the body.
Choice B is correct because adding powdered milk to skim milk increases the protein content of the drink.
Powdered milk is a dairy product that contains protein, carbohydrates and fat.
Skim milk is a dairy product that contains protein and carbohydrates but no fat.
Choice C is correct because peanut butter is a good source of protein and healthy fats.
Peanut butter is a plant product that contains protein, fat and some carbohydrates.
Crackers are a grain product that contains mostly carbohydrates and some protein.
Choice D is correct because cream of tomato soup is a good source of protein and calories.
Cream of tomato soup is a processed food that contains tomatoes, cream, flour and seasonings.
Tomatoes are a vegetable that contains mostly water and some carbohydrates.
Cream is a dairy product that contains mostly fat and some protein.
Flour is a grain product that contains mostly carbohydrates and some protein.
Seasonings are herbs and spices that contain mostly flavor and some nutrients.
The normal range of protein intake for adults is 0.8 to 1 gram per kilogram of body weight per day.
This means that an adult who weighs 70 kilograms should consume about 56 to 70 grams of protein per day.
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