Author Question: A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a ... (Read 41 times)

ts19998 · **on:** Jun 27, 2018

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.

Question 2

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?

A) Butorphanol
B) Fentanyl
C) Naloxone
D) Promethazine

fatboyy09 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

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.

Answer to Question 2

C
Feedback:
Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the opioid.