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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale
The term “passenger” in the context of the 5 P’s of labor refers to the fetus. The size, presentation, and position of the fetus can all affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the fetus, so this is not the correct answer.
Choice B rationale
The term “passageway” refers to the birth canal, which includes the pelvis. The size and shape of the pelvis can greatly impact the progress of labor. If the provider comments that there is “plenty of room in the pelvis,” they are likely referring to the passageway. Therefore, this is the correct answer.
Choice C rationale
The term “powers” refers to the contractions during labor. The frequency, duration, and intensity of contractions can affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to contractions, so this is not the correct answer.
Choice D rationale
The term “position” refers to the mother’s position during labor. Different positions can help facilitate the progress of labor and can help with pain management. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the mother’s position, so this is not the correct answer.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.