A nurse has assessed a patient in labor.
The patient’s cervix is dilated 4 cm and 100% effaced.
The fetus is in the vertex presentation at -1 station.
The patient is walking to the bathroom and experiences a spontaneous rupture of membranes.
What is the nurse’s priority action?

Assess the amniotic fluid.

Walk the patient to the bathroom.

Call and inform the healthcare provider.

Assist the patient back to bed and initiate fetal monitoring.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Assessing the amniotic fluid is important after rupture of membranes, but it is not the immediate priority. The nurse should first ensure the safety of the mother and baby.

Choice B rationale

Walking the patient to the bathroom is not the immediate priority. After rupture of membranes, the patient should be assisted back to bed to prevent cord prolapse.

Choice C rationale

Calling and informing the healthcare provider is important, but it is not the first action. The nurse should first assist the patient back to bed and initiate fetal monitoring.

Choice D rationale

Assisting the patient back to bed and initiating fetal monitoring is the correct action. After rupture of membranes, the priority is to assess the fetal heart rate for any signs of distress, such as bradycardia, which could indicate cord prolapse.

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Correct Answer is C

Explanation

Choice A rationale

The statement about shock waves refers to a different procedure called extracorporeal shock wave lithotripsy, which is used to break up kidney stones and gallstones. It is not related to an oral cholangiogram.

Choice B rationale

An oral cholangiogram does not involve inserting a camera down the throat. This statement seems to refer to an endoscopic procedure, which is different from an oral cholangiogram.

Choice C rationale

This statement is correct. An oral cholangiogram is an X-ray examination of the gallbladder and bile ducts. The patient takes an oral medication that makes these structures more visible on the X-ray.

Choice D rationale

This statement is incorrect. An oral cholangiogram does not involve putting medication into the gallbladder to dissolve stones. This seems to refer to a different treatment approach.

A. “Taking the medication between meals will help you absorb the medication more efficiently.”. B. “The medication can cause nausea if taken with food.”. C. “Taking the medication with food increases the risk of esophagitis.”. D. “Taking the medication between meals will help you avoid becoming constipated.”.

Correct Answer is A

Explanation

Choice A rationale

Taking ferrous sulfate between meals can help increase absorption of the medication. Iron is best absorbed on an empty stomach. However, it may need to be taken with food to reduce stomach upset.

Choice B rationale

While it’s true that ferrous sulfate can cause nausea, this is not the primary reason for taking it between meals. The main goal is to enhance absorption.

Choice C rationale

There’s no evidence to suggest that taking ferrous sulfate with food increases the risk of esophagitis.

Choice D rationale

While constipation can be a side effect of ferrous sulfate, taking it between meals does not necessarily prevent this.

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A nurse has assessed a patient in labor.The patient’s cervix is dilated 4 cm and 100% effaced.The fetus is in the vertex presentation at -1 station.The patient is walking to the bathroom and experiences a spontaneous rupture of membranes.What is the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a patient diagnosed with cholelithiasis about the upcoming oral cholangiogram.Which statement by the patient indicates that the education was effective?

Correct Answer is C

Explanation

A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia.The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals.Which of the following responses should the nurse make?

Correct Answer is A

Explanation

In the context of caring for a patient diagnosed with Crohn’s disease, which nursing assessment should be prioritized?

Exhibits Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for developing which of the following complications?

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A nurse has assessed a patient in labor.
The patient’s cervix is dilated 4 cm and 100% effaced.
The fetus is in the vertex presentation at -1 station.
The patient is walking to the bathroom and experiences a spontaneous rupture of membranes.
What is the nurse’s priority action?