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
Notifying the provider is important but does not address the immediate need to assess the patient's progress and readiness for delivery. A direct intervention is required to determine the next steps.
Choice B rationale
Performing a sterile vaginal exam allows the nurse to assess cervical dilation and effacement, fetal station, and presentation, which are crucial to determine if the patient is ready to push and proceed with delivery.
Choice C rationale
Supportive words and care are essential for patient comfort, but they do not provide the necessary assessment to determine the patient's progress in labor or readiness for pushing.
Choice D rationale
Monitoring the fetal heart rate tracing is important for assessing fetal well-being but does not specifically address the patient's readiness to push or her labor progress.
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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