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 A
Explanation
a. This is the correct statement for the treatment of chlamydia.
b. This is not the correct statement. Both partners should be treated.
c. The nurse should also advise the client to abstain from sexual relations for seven days after completing the treatment and to notify all sexual partners from the past 60 days to get tested and treated as well.
d. This is not the correct statement. Retesting should occur in 3-4 months.
Correct Answer is C
Explanation
a. The client should also be placed in Trendelenburg or knee-chest position to reduce cord compression.
b. This is not the first action to take when the umbilical cord is prolapsed.
c. This is a medical emergency that requires immediate intervention to prevent fetal hypoxia and death. The nurse should insert a gloved hand into the vagina and apply upward pressure on the presenting part to lift it off the cord until delivery.
d. This may be necessary if the cord compression cannot be relieved, but the first priority is to relieve the cord compression.
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