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

While altered mucus membranes can occur in patients with Crohn’s disease, it is not typically the primary nursing assessment.

Choice B rationale

Fluid volume deficit can occur in patients with Crohn’s disease due to diarrhea, a common symptom of the disease. However, it is not typically the primary nursing assessment.

Choice C rationale

Nutrition should be prioritized in the nursing assessment for a patient diagnosed with Crohn’s disease. Malnutrition can occur due to decreased appetite, malabsorption of nutrients, and increased nutritional needs due to inflammation.

Choice D rationale

While skin integrity can be a concern in patients with Crohn’s disease, particularly those with fistulas, it is not typically the primary nursing assessment.

A. Vitamin K B. Protamine C. Epinephrine D. Vitamin D .

Correct Answer is A

Explanation

Choice A rationale

Vitamin K is used to reverse the effects of warfarin. Warfarin is an anticoagulant that works by inhibiting the synthesis of vitamin K-dependent clotting factors. When the INR is too high, indicating a high risk of bleeding, vitamin K can be administered to increase the production of clotting factors and reduce the risk.

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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

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

Correct Answer is C

Explanation

A nurse is caring for a client who is on warfarin therapy for atrial fibrillation.The client’s INR is 5.2. Which of the following medications should the nurse prepare to administer?

Correct Answer is A

Explanation

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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?