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 C
Explanation
Choice A rationale
A station of -3 would indicate that the presenting part is 3 cm above the ischial spines. The ischial spines are the landmark for zero station. The picture shows the darkened line below the ischial spines, which corresponds to a positive number.
Choice B rationale
A station of -2 would indicate that the presenting part is 2 cm above the ischial spines. The ischial spines are the landmark for zero station. The picture shows the darkened line below the ischial spines, which corresponds to a positive number.
Choice C rationale
The ischial spines are the anatomical landmark for a fetal station of zero. The picture shows a darkened line that is positioned 2 cm below this landmark. Therefore, the fetal station is +2. A positive number indicates the fetus has descended past the ischial spines.
Choice D rationale
A station of +3 would indicate that the presenting part is 3 cm below the ischial spines. The picture shows the darkened line at the +2 mark, not the +3 mark. A positive number indicates the presenting part has descended past the ischial spines.
Correct Answer is D
Explanation
Choice A rationale
This choice is incorrect because it inaccurately defines the meaning of the clinical findings. Effacement is measured as a percentage, not in centimeters. The station, indicated by a positive or negative number, represents the fetal head's position relative to the ischial spines, not the cervix. A negative number indicates the head is positioned above the ischial spines.
Choice B rationale
This choice is incorrect because it reverses the definitions of dilation and effacement. Dilation is measured in centimeters (cm), while effacement is measured as a percentage. Additionally, a negative station number indicates that the presenting part is above the ischial spines, not below them.
Choice C rationale
This choice is incorrect because it reverses the definitions of dilation and effacement. Dilation is measured in centimeters, while effacement is measured as a percentage. The station, a negative number like -2, correctly indicates that the presenting part is above the ischial spines.
Choice D rationale
This choice is correct because it accurately interprets the three parameters of a vaginal examination. The first number, 3 cm, indicates cervical dilation. The second number, 30%, represents cervical effacement. The third number, -2, signifies that the presenting part is 2 cm above the ischial spines. This is a fundamental assessment in labor.
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