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

A sweat test is used to diagnose cystic fibrosis, a genetic disorder that affects the lungs and digestive system. It is not used to diagnose pernicious anemia.

Choice B rationale

Haptoglobin is a protein produced by the liver that binds to hemoglobin in the blood to prevent it from being excreted through the kidneys. While it can be used to diagnose conditions that cause the destruction of red blood cells, it is not used to diagnose pernicious anemia.

Choice C rationale

The Schilling test is used to determine whether the body absorbs vitamin B12 normally, which is crucial for the diagnosis of pernicious anemia. Pernicious anemia is a condition where the body is unable to absorb vitamin B12 due to a lack of intrinsic factor, a protein made in the stomach.

Choice D rationale

Antinuclear antibodies (ANAs) are a type of autoantibody that can attack the body’s own tissues. While they can be present in various autoimmune diseases, they are not used to diagnose pernicious anemia.

A. Fetal motion. B. Fetal neck translucency. C. Fetal gender. D. Fetal breathing. E. Amniotic fluid volume.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale

Fetal motion is indeed evaluated during a biophysical profile. It assesses the health of the baby by observing its movements16.

Choice B rationale

Fetal neck translucency is not evaluated during a biophysical profile. It is usually measured during an ultrasound examination in the first trimester of pregnancy as a part of screening for chromosomal abnormalities.

Choice C rationale

Fetal gender is not evaluated during a biophysical profile. The focus of a biophysical profile is on the baby’s health, not its gender16.

Choice D rationale

Fetal breathing is indeed evaluated during a biophysical profile. It assesses the health of the baby by observing its breathing movements16.

Choice E rationale

Amniotic fluid volume is indeed evaluated during a biophysical profile. It assesses the health of the baby by measuring the amount of amniotic fluid surrounding the fetus in the uterus16.

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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 providing care for a patient who the healthcare provider suspects may have pernicious anemia.Which diagnostic test should the nurse anticipate the healthcare provider will order?

Correct Answer is C

Explanation

A nurse is caring for a patient who is about to undergo a biophysical profile.The patient asks the nurse what will be evaluated during this test.Which of the following should the nurse include? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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

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?