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. Not satisfied with the nonpharmacological comfort measures. This describes dissatisfaction with pain management but does not specifically indicate a change in labor phase.

B. Active phase of labor. Nausea, irritability, and feelings of helplessness are classic signs of transitioning from the latent phase to the active phase of labor, when contractions become stronger and more intense.

C. Going to require more pain medication: Although the patient may need additional pain relief, the question is asking about labor progression, not pain management.

D. Going to have a long labor. Irritability and nausea are signs of labor progression, not necessarily an indicator of a long labor.

A. "The purpose of this medication is to boost fetal lung maturity." B. "The purpose of this medication is to stop preterm labor contractions." C. "The purpose of this medication is to halt cervical dilation." D. "The purpose of this medication is to increase the fetal heart rate."

Correct Answer is A

Explanation

A. "The purpose of this medication is to boost fetal lung maturity." Betamethasone is a corticosteroid given to promote fetal lung maturity by stimulating surfactant production, especially in preterm labor.

B. "The purpose of this medication is to stop preterm labor contractions." Tocolytics, not corticosteroids, are used to stop preterm labor contractions. Betamethasone is not designed to halt contractions.

C. "The purpose of this medication is to halt cervical dilation." Betamethasone does not affect cervical dilation. Its role is to support fetal lung development.

D. "The purpose of this medication is to increase the fetal heart rate." Betamethasone does not directly influence fetal heart rate. Its primary use is to mature fetal lungs in anticipation of early birth.

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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

A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

Correct Answer is B

Explanation

A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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