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 A
Explanation
Choice A rationale
Quickening, the first fetal movements felt by the mother, typically occurs between 16 and 20 weeks of gestation, so she should expect to feel fluttering sensations within the next month.
Choice B rationale
At 15 weeks of gestation, it is too early for most first-time mothers to feel fetal movements. Quickening usually occurs between 16 and 20 weeks, so she has not missed the window.
Choice C rationale
While some fetal movements may be subtle, it is inaccurate to suggest that some babies are entirely quiet. Quickening is generally felt by most mothers between 16 and 20 weeks.
Choice D rationale
The baby is indeed moving, but fetal movements are usually not felt until 16 to 20 weeks of gestation in first-time pregnancies, so it is normal not to feel them yet at 15 weeks.
Correct Answer is A
Explanation
Choice A rationale
Meconium is produced by the fetal intestines. The intestines start to form meconium around the 16th week of gestation. Meconium is composed of shed cells, mucus, amniotic fluid, bile, and lanugo.
Choice B rationale
The placenta does not produce meconium. Its primary functions include nutrient transfer, gas exchange, and waste elimination, but it does not have the structures necessary for the production of meconium.
Choice C rationale
Amniotic fluid does not produce meconium. Amniotic fluid surrounds and protects the fetus but does not contain the components needed to create meconium. Instead, the fetus swallows and then excretes it into the intestines.
Choice D rationale
Fetal kidneys are responsible for filtering waste and producing urine, but they do not produce meconium. The production of meconium is a function of the intestines, not the kidneys.
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