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 D

Explanation

A. "Count the fetal heart rate for 15 seconds to determine the baseline." The fetal heart rate (FHR) should be counted for a full minute to determine the baseline, not just for 15 seconds.

B. "Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor." The fetal heart rate is typically auscultated every 30 minutes in low-risk clients during the first stage of labor.

C. "Auscultate the fetal heart rate every 30 minutes during the second stage of labor." The fetal heart rate should be auscultated every 15 minutes during the second stage of labor, not every 30 minutes.

D. "Count the fetal heart rate after a contraction to determine baseline changes." It is important to assess the fetal heart rate after a contraction to determine if there are any decelerations or baseline changes that may indicate fetal distress.

A. To identify the mother's risk for complications B. To monitor the baby's oxygenation and overall well-being C. To predict the baby's birth weight D. To determine the baby's gender

Correct Answer is B

Explanation

A. To identify the mother's risk for complications. While maternal complications may indirectly affect the fetus, fetal heart rate monitoring is focused on the baby’s well-being.

B. To monitor the baby's oxygenation and overall well-being. Fetal heart rate monitoring primarily assesses the baby’s oxygenation and detects signs of distress (e.g., bradycardia or tachycardia).

C. To predict the baby's birth weight. Fetal heart rate monitoring does not predict birth weight.

D. To determine the baby's gender. Fetal heart rate monitoring cannot determine the baby’s gender.

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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:

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Naxlex Comprehensive Predictor Exams

A nurse is discussing intermittent fetal heart monitoring with a newly licensed nurse. Which of the following statements should the nurse include?

Correct Answer is D

Explanation

What is the primary purpose of assessing fetal heart rate patterns during labor and delivery?

Correct Answer is B

Explanation

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