Situation: a multigravid client at 34 weeks AOG is experiencing contraction every 3 to 4 minutes lasting for 3 seconds. Her cervix is 2 cm dilated and

.
Situation: a multigravid client at 34 weeks AOG is experiencing contraction every 3 to 4 minutes lasting for 3 seconds. Her cervix is 2 cm dilated and 50% effaced.

The leaking fluid is tested with nitrazine paper, the nurse comfirms ROM when the paper turns:

a. Blue
b. Yellow
c. Green
d. Red






Answer:
a. Blue

Situation: a multigravid client at 34 weeks AOG is experiencing contraction every 3 to 4 minutes lasting for 3 seconds. Her cervix is 2 cm dilated and

.
Situation: a multigravid client at 34 weeks AOG is experiencing contraction every 3 to 4 minutes lasting for 3 seconds. Her cervix is 2 cm dilated and 50% effaced.

Thirty hours after membrane rupture, what should be the priority assessment:

a. Temperature
b. RBC count
c. Urinary output
d. Uterine contraction






Answer:
a. Temperature

Situation: a multigravid client at 34 weeks AOG is experiencing contraction every 3 to 4 minutes lasting for 3 seconds. Her cervix is 2 cm dilated and

.
Situation: a multigravid client at 34 weeks AOG is experiencing contraction every 3 to 4 minutes lasting for 3 seconds. Her cervix is 2 cm dilated and 50% effaced.

Upon assessment, the client states that she might have broken her bag of water. Which of the following should the nurse do first:

a. Turn the client to the right side
b. Check the status of the fetal heart rate
c. Test the leaking fluid with nitrazine paper
d. Perform a sterile vaginal examination






Answer:
b. Check the status of the fetal heart rate