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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Testosterone is primarily a male hormone and does not play a role in pregnancy detection. Its presence would not indicate pregnancy or contribute to a positive pregnancy test result.
Choice B rationale
Progesterone supports pregnancy by maintaining the uterine lining but is not the hormone detected by pregnancy tests. Its levels do rise in pregnancy, but it is not used as a marker for detection.
Choice C rationale
Human Chorionic Gonadotropin (HCG) is produced by the placenta shortly after fertilization. Its presence in urine or blood is the basis for positive pregnancy test results. Normal HCG levels rise rapidly in early pregnancy.
Choice D rationale
Estrogen levels increase during pregnancy, but like progesterone, it is not used for pregnancy detection. Estrogen supports various pregnancy-related functions but is not detected in pregnancy tests.

A. Fetal movement felt by pregnant woman. B. Fetal heart rate noted on ultrasound. C. A positive pregnancy test. D. Braxton Hicks contractions.

Correct Answer is B

Explanation

Choice A rationale
Fetal movement felt by the pregnant woman is a presumptive sign of pregnancy, indicating probable fetal presence, but not definitive evidence.
Choice B rationale
Fetal heart rate noted on ultrasound is a positive sign of pregnancy, providing objective evidence of fetal existence within the uterus.
Choice C rationale
A positive pregnancy test indicates probable pregnancy due to hormonal presence, but it is not a definitive confirmation without further clinical evidence.
Choice D rationale
Braxton Hicks contractions are considered probable signs of pregnancy, as they indicate uterine activity without confirming the presence of a fetus.

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A multipara in latent phase of labor experiences spontaneous rupture of membranes while walking. Which is the first priority nursing action?

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Naxlex Comprehensive Predictor Exams

Jana purchased an over-the-counter pregnancy test. The results were positive. The hormone responsible for a positive pregnancy test is:

Correct Answer is C

Explanation

The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates understanding of the nurse’s instructions if she states that a positive sign of pregnancy is:

Correct Answer is B

Explanation

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Along with gas exchange and nutrient transfer, the placenta produces many hormones necessary for normal pregnancy. These include (select all that apply)

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The nurse places a Toco (tocodynamometer) on a client admitted in early labor. The nurse explains to the client that this device provides an accurate assessment of which of the following:

A multipara in latent phase of labor experiences spontaneous rupture of membranes while walking.

Which is the first priority nursing action?