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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is E
Explanation
a. Inevitable abortion is characterized by vaginal bleeding, cramping, and dilated cervical os.
b. Septic abortion is associated with infection and may present with fever, chills, and foul-smelling vaginal discharge.
c. Incomplete abortion involves vaginal bleeding, cramping, and dilation of the cervical os with passage of some products of conception.
d. A missed abortion is when there is no bleeding or cramping, but the pregnancy has stopped developing and there is no fetal heartbeat. The cervix may be closed or slightly open, and the uterus may be smaller than expected for gestational age.
e. Threatened abortion involves vaginal bleeding with a closed cervical os and no passage of products of conception. It signifies a potential abortion, but the pregnancy may continue.
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