A pregnant patient's amniotic membranes rupture.
What intervention would be the top priority?
Starting oxygen by face mask.
Checking fetal heart rate.
Preparing the woman for a cesarean birth.
Placing the woman in the knee-chest position.
The Correct Answer is B
Choice A rationale
While oxygen administration may be indicated for signs of fetal distress, it is not the top priority. The most critical risk immediately following membrane rupture is the possibility of a prolapsed umbilical cord. Administering oxygen doesn’t address this immediate mechanical risk. The primary intervention must be to assess for cord prolapse by checking the fetal heart rate for signs of compression.
Choice B rationale
The top priority intervention immediately following a rupture of membranes is to assess the fetal heart rate. The most significant risk is a prolapsed umbilical cord, which can be compressed between the fetal presenting part and the maternal pelvis. This compression compromises fetal oxygenation, leading to a sudden and severe drop in fetal heart rate, which is a life-threatening emergency.
Choice C rationale
Preparing for a cesarean birth is a potential intervention if there is evidence of a prolapsed cord or severe fetal distress. However, it is not the initial priority. The first step is to assess the situation by checking the fetal heart rate to determine if an emergency exists. A cesarean is a consequence of a serious finding, not the first-line intervention.
Choice D rationale
Placing the woman in a knee-chest or Trendelenburg position is an intervention used to relieve pressure on a prolapsed umbilical cord once it has been identified. This is a crucial intervention, but it is not the very first step. The first priority is to identify if cord prolapse has occurred by checking the fetal heart rate, which dictates whether this position change is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.25"]
Explanation
Step 1 is: 12.5 mg ÷ (50 mg ÷ 1 mL) = 0.25 mL. The final calculated answer is 0.25 mL.
Correct Answer is A
Explanation
Choice A rationale
Naloxone is a potent, competitive opioid receptor antagonist. Administering it to an opioid-dependent individual can precipitate an acute and severe withdrawal syndrome. This occurs because naloxone rapidly displaces all opioids from their receptors, leading to an immediate reversal of both the analgesic and depressant effects, as well as the physiological dependence that has developed.
Choice B rationale
This statement is incorrect because the risk of precipitating acute withdrawal in opioid-dependent patients is a well-established and significant clinical consideration. Naloxone is indicated for opioid overdose, but its use in dependent patients requires careful management to avoid severe adverse effects.
Choice C rationale
The effect of naloxone is not a matter of "maybe.”. The pharmacological response is predictable and directly related to the patient's opioid dependency status. The certainty of precipitating withdrawal in a dependent individual is the primary reason for caution.
Choice D rationale
The patient's age is a factor in determining the dosage and potential side effects of naloxone, but it does not change the fundamental pharmacological interaction with opioid receptors in a dependent individual. The core issue is the presence of physical dependence on opioids, regardless of age.
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