A multipara in latent phase of labor experiences spontaneous rupture of membranes while walking.

Which is the first priority nursing action?

Test the fluid with nitrazine paper to confirm membrane rupture.

Document the time of rupture of membranes.

Monitor the fetal heart rate and pattern.

Notify the physician or midwife immediately.

Answer and Explanation

The Correct Answer is C

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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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.

A. The bacteria cause perineal sepsis. B. The client is at risk for chorioamnionitis. C. The bacteria are sexually transmitted. D. The baby is at high risk for neonatal sepsis.

Correct Answer is D

Explanation

Choice A rationale
Group B Streptococcus (GBS) is not typically associated with perineal sepsis; rather, it is a bacterium that colonizes the gastrointestinal and genitourinary tracts.
Choice B rationale
While GBS colonization can pose risks, chorioamnionitis is a different infection involving the membranes and amniotic fluid, often caused by a variety of microorganisms, not solely GBS.
Choice C rationale
GBS is not primarily sexually transmitted; it is a bacterium naturally present in the genital and digestive tracts, and colonization can occur without sexual contact.
Choice D rationale
Neonatal sepsis is a serious risk for babies born to mothers colonized with GBS, necessitating antibiotic prophylaxis to prevent transmission and subsequent infection in the newborn.

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A multipara in latent phase of labor experiences spontaneous rupture of membranes while walking. Which is the first priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is discussing a patient’s vaccination history at her 32-week gestation appointment. The nurse knows that her teaching has been effective when the patient states:

Correct Answer is B

Explanation

A physician writes the following order: administer ampicillin 1 g IV every 4 hours until delivery for a newly admitted client with ruptured membranes. The client had positive vaginal and rectal cultures for GBS+ at 36 weeks gestation. Which of the following is a rationale for this order?

Correct Answer is D

Explanation

This procedure allows us to identify fetal lie, presentation, and engagement:

After the nurse completes nutritional counseling for a pregnant woman, she asks the client to repeat the instructions to assess the client’s understanding. Which statement indicates that the client understands the role of protein in her pregnancy?

A woman in labor has just received an epidural block. The most important nursing intervention is to:

The fetal monitor tracing shown is associated with:

The nurse caring for the laboring woman should understand that early decelerations are caused by:

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is:

The slight overlapping of cranial bones or shaping of the fetal head during labor is called:

A multipara in latent phase of labor experiences spontaneous rupture of membranes while walking.

Which is the first priority nursing action?