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 D
Explanation
a. This is not the correct diagnosis for this situation.
b. This is not the correct diagnosis for this situation.
c. This is not the correct diagnosis for this situation.
d. The sudden onset of increased contraction frequency, dark red vaginal bleeding, and severe abdominal pain are characteristic of placental abruption.
Correct Answer is B
Explanation
a. The second stage of labor begins when the cervix is fully dilated and ends with the birth of the baby. The latent phase is the early part of the second stage when the woman may be resting between contractions.
b. The first stage, transition phase is from 8 to 10 cm dilation, with strong and frequent contractions.
c. The first stage, latent phase is the early part of the first stage of labor when the cervix is dilated from 0 to 4 cm and contractions are mild and irregular.
d. The first stage, active phase is from 4 to 7 cm dilation, with moderate and regular contractions.
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