As a woman enters the second stage of labor, her membranes spontaneously rupture. What action should the nurse take?

Check fetal heart rate

instruct her to bare down with the next contraction

Place her legs in stirrups

Test a sample of the amniotic fluid for meconium

Answer and Explanation

The Correct Answer is A

A) Check fetal heart rate:
The first priority when a woman's membranes spontaneously rupture is to assess fetal well-being. The nurse should immediately check the fetal heart rate (FHR) after the rupture of membranes to evaluate for any signs of fetal distress. If there are any concerns regarding the FHR, further interventions may be needed, such as adjusting the maternal position or preparing for a possible emergent delivery. Monitoring the FHR will help guide subsequent decisions regarding care.

B) Instruct her to bear down with the next contraction:
While the second stage of labor involves pushing, it is important to wait for the appropriate signs of readiness before instructing the mother to bear down. The nurse should ensure the cervix is fully dilated and that fetal descent is progressing appropriately. Rushing into pushing too early or without proper readiness can lead to maternal and fetal complications.

C) Place her legs in stirrups:
Placing the mother’s legs in stirrups is typically done once she is in the active phase of pushing (typically when the cervix is fully dilated and fetal descent is ready). It is not the first priority immediately after the membranes rupture. The nurse should first assess the fetal heart rate and ensure the woman is comfortable and ready to push before assuming the lithotomy position or placing her legs in stirrups.

D) Test a sample of the amniotic fluid for meconium:
Testing the amniotic fluid for meconium should be done if there is concern that the amniotic fluid may be stained, as meconium in the amniotic fluid can be a sign of fetal distress. However, the first action after the membranes rupture is to check the fetal heart rate. If the FHR is normal, further actions, like testing the fluid, may follow, but the priority remains assessing fetal well-being.

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Correct Answer is ["C","E","H","I"]

Explanation

Findings that require follow-up:

Uterus boggy at 24 hr postpartum:

A boggy uterus indicates poor uterine contraction, which can lead to postpartum hemorrhage. Effective uterine contraction is crucial to prevent excessive bleeding after delivery, and this finding warrants immediate intervention, such as fundal massage or administering uterotonic medications.

Lochia rubra with foul odor:

Foul-smelling lochia is a sign of potential infection, often indicative of endometritis, which is an infection of the uterine lining. The presence of this odor requires prompt follow-up and possibly antibiotic treatment to prevent further complications.

Elevated temperature (38.3°C/100.9°F) at 24 hr postpartum:

A postpartum fever may indicate infection, such as endometritis or a urinary tract infection (UTI). This fever should be investigated further to determine the cause and appropriate treatment, as untreated infections can lead to serious complications.

Increased heart rate (105/min) at 24 hr postpartum:

Tachycardia in the postpartum period can be a sign of infection or early signs of hemodynamic instability, possibly due to blood loss or infection. Close monitoring is necessary, and the healthcare provider should be notified to evaluate the cause and initiate treatment if necessary.

A. Apply petrolatum to penis with each diaper change B. Use a diaper barrier cream that contains zinc oxide C. Use alcohol-based baby wipes on the soiled genital area D. Fold the diaper below the umbilical cord at all times E. Apply alcohol to the umbilical stump with a diaper change F. Use a soft-bristled brush with mild shampoo to wash the head G. Bathe in a shallow warm tub every other day H. Cover the hands with socks or sleeves at all times I. Apply mildly scented lotion to face as needed

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"B"},"I":{"answers":"B"}}

Explanation

Apply petrolatum to penis with each diaper change: Applying petrolatum prevents the healing circumcision site from adhering to the diaper, reducing pain and promoting proper healing.
Use a diaper barrier cream that contains zinc oxid: Zinc oxide is used for diaper rash treatment but is not routinely necessary. It may interfere with circumcision healing by creating a barrier that retains moisture.
Use alcohol-based baby wipes on the soiled genital area: Alcohol-based wipes can be too harsh on a newborn’s delicate skin and may cause irritation, especially on the healing circumcision site.
Fold the diaper below the umbilical cord at all times: Folding the diaper below the umbilical cord keeps the area dry and exposed to air, promoting natural drying and reducing the risk of infection.
Apply alcohol to the umbilical stump with a diaper change: Alcohol was previously used to dry the cord, but current guidelines recommend keeping it clean and dry, allowing it to fall off naturally.
Use a soft-bristled brush with mild shampoo to wash the head: A soft-bristled brush helps loosen cradle cap (seborrheic dermatitis), preventing buildup of flaky skin without causing irritation.
Bathe in a shallow warm tub every other day: Full immersion bathing should be avoided until the umbilical cord stump falls off to prevent moisture retention and infection. Sponge baths are recommended instead.
Cover the hands with socks or sleeves at all times: While covering hands temporarily can prevent scratches, prolonged covering may interfere with newborn sensory development and exploration.
Apply mildly scented lotion to face as needed: Newborn skin is sensitive, and scented lotions may cause irritation or allergic reactions. If needed, only fragrance-free moisturizers should be used.

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As a woman enters the second stage of labor, her membranes spontaneously rupture. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","E","H","I"]

Explanation

A nurse is assisting in the care of a newborn. Exhibits A nurse is reinforcing discharge education with the parents of a newborn. For each potential point, click to specify if the teaching is anticipated or contraindicated for the newborn.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"B"},"I":{"answers":"B"}}

Explanation

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