You are working in the labor and delivery unit, you received several nursing reports.
Which patient should you assess first?
Select one:
A 27-year-old G2P1 woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago but feels normal fetal movements and not contractions are noted.
A 22-year-old. 9cm 100% +4. Who is requesting to go to the bathroom to have a bowel movement
A 32-year-old G4P3 woman at 27 weeks' gestation who noted scan vaginal bleeding today, after of having a sexual intercourse in the morning.
A 17-year-old. 2cm 80% -2. Who is crying and shows mild anxiety
The Correct Answer is B
a. A woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago with normal fetal movements is not a priority assessment as long as there are no signs of fetal distress.
b. A woman who is 9 cm dilated and fully effaced and is requesting to go to the bathroom to have a bowel movement is in the second stage of labor, which means that the cervix is fully dilated and the fetus is descending in the birth canal. The urge to have a bowel movement is a sign that the fetal head is pressing on the rectum and that delivery is imminent. This patient needs immediate attention and preparation for delivery.
c. A woman at 27 weeks' gestation who noted scant vaginal bleeding today after having sexual intercourse in the morning may be experiencing placenta previa or placental abruption but this is not a priority compared to the woman in option b who is yet to deliver.
d. A woman who is 2 cm dilated and 80% effaced and is crying and shows mild anxiety is not a priority assessment as long as there are no signs of fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Not every woman ovulates on day 14 of her cycle, and the basal temperature only rises after ovulation, not before.
b. The basal temperature is the lowest body temperature during a 24-hour period.
It is usually measured first thing in the morning before any physical activity or eating. The basal temperature can indicate when a woman is ovulating, as it tends to rise slightly (about 0.5°F or 0.3°C) after ovulation and remain elevated until the next menstrual period. By tracking the basal temperature over several cycles, a woman can identify her most fertile days and plan accordingly.
c. Intercourse can affect the body temperature and give a false reading.
d. The basal temperature is influenced by factors such as food, drink, stress, and activity, so it should be measured before any of these occur.
Correct Answer is B
Explanation
a. Maternal hypotension is not a common side effect of terbutaline, which is a beta-adrenergic agonist that can cause tachycardia and hypertension.
b. Pulmonary edema is a serious complication of terbutaline therapy, which can cause fluid overload, dyspnea, chest pain, and crackles in the lungs. The nurse should monitor the woman's vital signs, oxygen saturation, urine output, and lung sounds, and report any signs of pulmonary edema to the physician immediately.
c. Fetal bradycardia is not related to terbutaline, which can cause fetal tachycardia.
d. Fetal hypokalemia is also not associated with terbutaline, which can cause maternal hypokalemia due to increased potassium uptake by the cells.
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