A client is admitted to the birthing suite in early active labor.
Which nursing action takes priority during the admission process?

Determining when the last meal was eaten.

Ascertaining whether the membranes have ruptured.

Obtaining an obstetric history.

Auscultating the fetal heart.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Determining when the last meal was eaten is important for assessing aspiration risk, especially if an emergency cesarean section is needed, which is a key safety measure. However, this is a secondary concern to establishing the fetal status. Fetal well-being is the highest priority upon admission for a woman in labor, as indicated by monitoring the fetal heart rate.

Choice B rationale

Ascertaining whether the membranes have ruptured is necessary because rupture of membranes increases the risk of infection (chorioamnionitis) and can be associated with cord prolapse. While critical for infection control and assessing the risk of cord prolapse, this action does not take priority over the immediate evaluation of fetal status and oxygenation through heart auscultation.

Choice C rationale

Obtaining a comprehensive obstetric history (parity, previous birth experiences, complications, etc.) is essential for planning care and identifying risk factors. This information helps the nurse and provider anticipate potential complications during labor and delivery. However, it is an administrative and data-gathering task that can be performed after the immediate assessment of the maternal and fetal status.

Choice D rationale

Auscultating the fetal heart is the highest priority upon admission of a laboring patient. This action immediately assesses the current fetal status, specifically the heart rate and its pattern, which are the most critical indicators of fetal oxygenation and well-being. Any signs of fetal distress, such as a nonreassuring heart rate pattern, require immediate intervention and supersede all other admission tasks.

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Correct Answer is E

Explanation

Choice A rationale

The third stage of labor, which begins after the baby is born and ends with the delivery of the placenta, is too late to discuss options for pharmacologic pain relief for the active process of contractions and birth, as the painful part of labor is nearly over.

Choice B rationale

Attempting to discuss complex choices like pharmacologic pain relief options during a uterine contraction is counterproductive because the patient will be focused on coping with the pain and is unlikely to comprehend or process new information effectively.

Choice C rationale

While discussing options between contractions is better than during, the latent phase upon admission offers the most relaxed and appropriate time for comprehensive discussion of the birth plan and pain management choices before labor intensifies significantly.

Choice D rationale

The second stage of labor, which involves pushing and the birth of the baby, is too late for the initial detailed discussion and informed consent process required for most pharmacologic pain relief methods, as the urgency of delivery is paramount.

Choice E rationale

Upon admission during the latent phase of labor (cervical dilation 0-6 cm), contractions are mild and the patient is relatively comfortable, providing a calm window for the nurse to review the birth plan, ensure informed consent, and discuss all available pharmacologic options thoroughly.

A. 1/9/2024. B. 6/28/2024. C. 7/21/2024. D. 7/7/2024.

Correct Answer is C

Explanation

Step 1 is: Subtract 3 months from the month of the last menstrual period (LMP) and add 7 days to the day of the LMP.

Step 2 is: The LMP month is 10 (October). Subtract 3 months: 10 minus 3 equals 7 (July).

Step 3 is: The LMP day is 14. Add 7 days: 14 plus 7 equals 21.

Step 4 is: Naegele's rule also requires adjusting the year forward by one year because the calculation crosses the calendar year boundary, which is 2023 plus 1 equals 2024.

Step 5 is: The estimated due date (EDD) is July 21, 2024.

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A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient has shared a copy of her birth plan with the nurse. When is the best time for the nurse to review the birth plan and discuss the patient's options for pharmacologic pain relief in labor?

Correct Answer is E

Explanation

The nurse receives a call at the provider's office with a patient asking what her estimated due date is. The last menstrual period was on 10/14/2023. Using Naegele's rule, the nurse determines that the EDD is:

Correct Answer is C

Explanation

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A client is admitted to the birthing suite in early active labor.
Which nursing action takes priority during the admission process?