A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. Which of the following would the nurse do next?
A) Check the fetal heart rate.
B) Perform a vaginal exam.
C) Notify the physician immediately.
D) Change the linen saver pad.
A
Feedback:
When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The physician should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the physician has been notified.
You might also like to view...
The nurse is aware that the refractive media of the eye is made up of the (select all that apply):
1. aqueous humor. 2. retina. 3. vitreous humor. 4. cornea. 5. lens.
The nurse would explain to a client who reports being frequently short of breath that the most common form of dyspnea associated with cardiac disorders is
a. exertional dyspnea. b. idiopathic dyspnea. c. orthopnea. d. paroxysmal nocturnal dyspnea.
Name the first positive deflection seen after the P wave on the ECG
What will be an ideal response?
A nurse is formulating the diagnostic statement for a client who had a motor vehicle accident. The healthcare facility where the nurse is employed uses a two-part diagnostic statement on the electronic medical record
The client has bruises in the anterior chest and is unable to move independently when sitting up or lying down. Which is the best example of a correct diagnostic statement? A) Impaired mobility of anterior chest related to bruises and swelling AEB motor vehicle accident B) Impaired mobility of anterior chest related to motor vehicle accident AEB bruises and swelling C) Impaired mobility of anterior chest AEB bruises and swelling D) Impaired movement of the anterior chest related to the motor vehicle accident