The nurse is caring for a gravida 5 in active labor. The ...

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The nurse is caring for a gravida 5 in active labor. The membranes spontaneously rupture, with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time?
 
  1. Assess the odor of the amniotic fluid.
  2. Perform Leopold's maneuvers.
  3. Obtain an order for pain medication.
  4. Complete a sterile vaginal exam.

Question 2

The nurse obtains a health history from four clients. To which client should she give priority for teaching about cervical cancer prevention?
 
  1. Age 37, multiple partners
  2. Age 22, abstains from sexual intercourse
  3. Age 32, pregnant with twins
  4. Age 27, uses female condom

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Answer to Question 1

4
Rationale 1: Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.
Rationale 2: This assessment is not called for at this time.
Rationale 3: Pain medication is a low priority at this time.
Rationale 4: Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated.

Answer to Question 2

1
Explanation: 1. Having multiple partners increases the client's risk of contracting sexually transmitted infections, including possible exposure to human papilloma virus (HPV). Contracting HPV increases risk of abnormal cervical cell changes and cervical cancer.