A laboring patient reports to the nurse that "I think my water just broke!" The first action the nurse should take is:

Check the fluid with Nitrazine paper

Assess the FHR

Note the color of the fluid

Notify the health care provider

Answer and Explanation

The Correct Answer is B

A. Check the fluid with Nitrazine paper. While this test can confirm if the membranes have ruptured, assessing the fetal heart rate (FHR) is more critical to ensure that there is no fetal distress due to umbilical cord prolapse.

B. Assess the FHR. After suspected rupture of membranes, the priority is to assess the fetal heart rate to check for potential complications like umbilical cord prolapse, which can cause fetal distress.

C. Note the color of the fluid. Assessing the color of the fluid is important, especially if meconium is present, but it is secondary to ensuring fetal well-being by assessing the FHR first.

D. Notify the health care provider. The provider should be notified, but the first action should be to assess the fetal heart rate to check for signs of distress.

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Correct Answer is B

Explanation

A. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days." A cephalhematoma is a collection of blood between the skull bone and periosteum, and it does not cross suture lines. Caput succedaneum, on the other hand, does cross suture lines.

B. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." Caput succedaneum is swelling of the soft tissues of the scalp caused by pressure during birth, especially with vacuum extraction, and it crosses suture lines.

C. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin." Erythema toxicum is a common newborn rash, but it does not cause swelling on the head or cross suture lines.

D. "This is a Mongolian spot, which is found on many newborns." Mongolian spots are bluish-gray marks usually found on the lower back or buttocks, not on the head, and they are not related to vacuum extraction or swelling.

A. Monitor the patient's urinary output. B. Monitor for tachysystole. C. Monitor the patient's coping mechanisms for labor. D. Monitor the IV site.

Correct Answer is B

Explanation

A. Monitor the patient's urinary output. While monitoring urinary output is important, it is not the primary concern when administering oxytocin for labor induction.

B. Monitor for tachysystole. Tachysystole (defined as more than 5 contractions in 10 minutes) is a potential complication of oxytocin administration. It can lead to fetal distress, so it is crucial to monitor for this condition.

C. Monitor the patient's coping mechanisms for labor. Monitoring coping mechanisms is important, but it is not the primary responsibility when administering oxytocin.

D. Monitor the IV site. While the IV site should be monitored for complications such as infiltration, it is not the primary concern with oxytocin administration.

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A laboring patient reports to the nurse that "I think my water just broke!" The first action the nurse should take is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A major responsibility of the nurse caring for a patient receiving oxytocin for labor induction is to

Correct Answer is B

Explanation

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