A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured spontaneously. The nurse's priority must be to:
Select one:
Prepare the woman for imminent birth
Assess the fetal heart rate and pattern
Notify the woman's primary health care provider
Document the characteristics of the fluid.
The Correct Answer is B
a. This may be necessary once fetal heart rate and pattern have been assessed, but it is not the initial priority.
b. This is the priority as it will help determine the next steps in the management of labor.
c. This may be necessary once fetal heart rate and pattern have been assessed, but it is not the initial priority.
d. This may be done after assessing the fetal heart rate and pattern, but it is not the initial priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. This does not follow the Nagele's rule.
b. Nagele's rule is a method to estimate the expected delivery date by adding 7 days and subtracting 3 months from the first day of the last normal menstrual period. In this case, adding 7 days to March 13 gives March 20, and subtracting 3 months gives December 20. Then, adding one year gives December 20, 2022.
c. This does not follow the Nagele's rule.
d. This does not follow the Nagele's rule.

Correct Answer is D
Explanation
a. This is not the correct action for this situation.
b. This is not the correct action for this situation.
c. This is not the correct action for this situation.
d. The patient is experiencing uterine tachysystole, which is defined as more than five contractions in 10 minutes, lasting longer than 90 seconds, or with less than 30 seconds of interval between contractions. This can cause fetal hypoxia and distress, as evidenced by late decelerations in the fetal heart rate tracing. The nurse should stop the oxytocin, increase the IV fluid rate, position the patient on her left side, administer oxygen, and notify the provider.
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