A multipara in latent phase of labor experiences spontaneous rupture of membranes while walking.
Which is the first priority nursing action?
Test the fluid with nitrazine paper to confirm membrane rupture.
Document the time of rupture of membranes.
Monitor the fetal heart rate and pattern.
Notify the physician or midwife immediately.
The Correct Answer is C
Choice A rationale
Testing the fluid with nitrazine paper can confirm membrane rupture but is not the first priority. Assessing the fetal heart rate is crucial to ensure fetal well-being immediately after membrane rupture.
Choice B rationale
Documenting the time of rupture is important for clinical records but is not the first priority. Immediate assessment of fetal status takes precedence to detect any distress.
Choice C rationale
Monitoring the fetal heart rate and pattern immediately after membrane rupture is essential to ensure the fetus is not in distress. It helps detect any complications like cord prolapse.
Choice D rationale
Notifying the physician or midwife is necessary but not the first priority. Ensuring fetal well-being through heart rate monitoring is the immediate concern following membrane rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Although the placenta acts as a partial barrier, it does not keep out all harmful substances, allowing some to cross and affect fetal development.
Choice B rationale
One of the placenta's early functions is producing hormones like human chorionic gonadotropin (hCG), estrogen, and progesterone, making it act as an endocrine gland.
Choice C rationale
The placenta does not thin out; it remains robust and increases in thickness to support the growing fetus and facilitate nutrient and gas exchange.
Choice D rationale
While optimal blood circulation through the placenta is crucial, this statement lacks detail on the specific structural and functional aspects of the placenta.
Correct Answer is B
Explanation
Choice A rationale
Continuing the same comfort methods that have become ineffective is unlikely to help the client and may increase frustration. Adaptation to the client’s changing needs is necessary for effective care.
Choice B rationale
Choosing an alternate method of comfort promotion is appropriate as it addresses the client's current needs and helps to alleviate frustration. Alternate methods might include massage, repositioning, or hydrotherapy.
Choice C rationale
Asking the support person to leave the room may not address the client's comfort needs and could decrease her emotional support, potentially increasing stress and frustration rather than providing relief.
Choice D rationale
Telling the client to relax more is not supportive and does not provide a new strategy to promote comfort. It may be dismissive and can increase the client’s frustration and anxiety during labor.
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