a laboring clients membranes have just ruptured what is the nurses next action a laboring clients membranes have just ruptured what is the nurses next action
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. What is the nurse's next action after a laboring client's membranes have just ruptured?

Correct answer: A

Rationale: After a laboring client's membranes have ruptured, the nurse's immediate priority is to assess the fetal heart rate pattern. This assessment is crucial to ensure the fetus is not in distress, especially to rule out umbilical cord compression that could affect blood flow to the fetus. While monitoring uterine contractions is important, assessing the fetal heart rate takes precedence in this situation as it directly reflects the fetus's well-being. Administering oxygen may be necessary later depending on the fetal status, and preparing for delivery should only occur if the assessment indicates fetal distress or other complications. Therefore, the correct next action for the nurse is to assess the fetal heart rate pattern.

2. A client with hypertension is prescribed a thiazide diuretic. What instruction should the nurse reinforce to the client?

Correct answer: C

Rationale: The correct answer is to weigh oneself daily. This instruction is important as daily weights help monitor fluid loss and are crucial for detecting early signs of fluid imbalance when taking a diuretic. Weighing daily allows for timely adjustments in treatment and helps prevent complications associated with fluid imbalance. Choice A is not directly related to the client's need for monitoring fluid balance. Choice B, although important for some diuretics, is not specific to thiazide diuretics. Choice D is not appropriate as limiting fluid intake without proper monitoring can lead to dehydration, especially when taking diuretics.

3. What are oligosaccharides composed of?

Correct answer: A

Rationale: Oligosaccharides are carbohydrates composed of 3 to 10 monosaccharide units, making choice A the correct answer. Choice B is incorrect as oligosaccharides do not contain partially digested starch. Choice C is incorrect as nonnutritive sweeteners are a different category of compounds. Choice D is incorrect as oligosaccharides are not primarily used for weight management.

4. What is the most effective way to prevent the spread of infection in a healthcare setting?

Correct answer: A

Rationale: Hand hygiene is considered the most effective method to prevent the spread of infection in a healthcare setting. Proper hand hygiene, including washing hands with soap and water or using hand sanitizer, is crucial in reducing the transmission of pathogens from one person to another. While wearing personal protective equipment, sterilizing equipment, and isolating infected patients are also important infection control measures, they are not as universally effective as hand hygiene in preventing the spread of infections. Personal protective equipment can prevent contact with infectious materials, sterilizing equipment reduces the risk of contamination, and isolating infected patients helps prevent the spread of specific infections, but they are more targeted approaches compared to the broad and essential practice of hand hygiene.

5. Cholecystokinin (CCK) is produced in the:

Correct answer: A

Rationale: Cholecystokinin (CCK) is produced in the duodenum, not the stomach, pancreas, or liver. It is released in response to the presence of food in the duodenum, where it plays a crucial role in regulating digestive processes by stimulating the release of bile from the gallbladder and enzymes from the pancreas. Therefore, the correct answer is the duodenum (Choice A). Choices B, C, and D are incorrect because CCK is not produced in the stomach, pancreas, or liver.

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