A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit.
The fetal heart rate has been normal.
Contractions are 10 to 15 minutes apart, 20 to 30 seconds in duration, and of mild intensity.
Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact.
The nurse should expect the woman to be:
Discharged home with a sedative.
Admitted and prepared for cesarean birth.
Admitted for extended observation.
Discharged home to await the onset of true labor.
The Correct Answer is A
Choice A rationale
Mild contractions and minimal cervical dilation suggest false labor. Administering a sedative helps the patient rest and wait for true labor onset. Sedatives can include sleep-inducing medications.
Choice B rationale
Cesarean birth is not indicated for a primigravida with mild contractions and minimal cervical dilation. This intervention is reserved for more serious obstetric complications.
Choice C rationale
Extended observation is unnecessary for mild contractions and unchanged cervical status. It is more appropriate for patients showing signs of true labor or complications.
Choice D rationale
True labor onset requires regular, increasing intensity contractions and cervical changes. Discharging the patient allows her to await true labor onset at home comfortably.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Rubella vaccination is contraindicated during pregnancy due to the live virus, which poses a risk to the fetus. Administration should occur postpartum to avoid congenital rubella syndrome in the infant.
Choice B rationale
This statement is correct as rubella vaccination should be deferred until after delivery. It avoids exposure to the live virus during pregnancy, protecting fetal health.
Choice C rationale
The Tdap vaccine is recommended during each pregnancy, typically between 27 and 36 weeks gestation, to boost maternal antibodies and provide passive immunity to the newborn.
Choice D rationale
The flu vaccine is recommended during pregnancy to protect both the mother and the baby from influenza. It reduces the risk of severe illness and complications from the flu.
Correct Answer is C
Explanation
Choice A rationale
Testing the fluid with nitrazine paper can confirm membrane rupture but is not the first priority. Assessing the fetal heart rate is crucial to ensure fetal well-being immediately after membrane rupture.
Choice B rationale
Documenting the time of rupture is important for clinical records but is not the first priority. Immediate assessment of fetal status takes precedence to detect any distress.
Choice C rationale
Monitoring the fetal heart rate and pattern immediately after membrane rupture is essential to ensure the fetus is not in distress. It helps detect any complications like cord prolapse.
Choice D rationale
Notifying the physician or midwife is necessary but not the first priority. Ensuring fetal well-being through heart rate monitoring is the immediate concern following membrane rupture.
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