The nurse is monitoring a client in labor whose membranes ...

[asd123]

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. The initial nursing action is to:
 
  1. Take the client's blood pressure.
  2. Provide peripads to the client.
  3. Determine the fetal heart rate.
  4. Note the amount, color, and odor of the amniotic fluid.

Question 2

The nurse who is assessing the client's eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as:
 
  1. Myopia
  2. Hyperopia
  3. Photophobia
  4. Accommodation

[miss_1456@hotmail.com]

Answer to Question 1

3

Rationale: When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Take the client's blood pressure. and Note the amount, color, and odor of the amniotic fluid. are also appropriate actions, but are not the initial actions in this situation. The nurse may assist the client in cleaning and changing clothing, but determining the fetal heart rate is the initial ac-tion.

Answer to Question 2

4

Rationale: Accommodation is the expected change in pupil size when changing gaze from a near object to a far one, and back again. The pupils dilate when looking at the far object and constrict when looking at the near one. Photophobia is an abnormal sensitivity to light. Myopia (nearsightedness) and hyperopia (farsightedness) are disturbances in visual acuity.

[asd123]

TY

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