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 D
Explanation
a. A scalp electrode is not indicated unless there is a problem with the external monitor tracing or if further assessment of the fetal heart rate variability is needed.
b. This is important but repositioning the patient is the priority.
c. Amnioinfusion is only done if repositioning the patient does not resolve the late decelerations.
d. The nurse is observing late decelerations of the fetal heart rate, which indicate uteroplacental insufficiency and fetal hypoxia. The nurse's first priority is to reposition the patient to improve placental blood flow and oxygen delivery to the fetus. Repositioning can be done by turning the patient to her side, elevating her legs, or placing a wedge under her hip.
Correct Answer is A
Explanation
a. Sleeping on the left side (lateral) is recommended during pregnancy to improve circulation and prevent dizziness.
b. This is not a practical or safe solution to prevent dizziness.
c. This may not be effective in preventing dizziness, and it is not recommended to elevate the head during sleep in late pregnancy.
d. Elevating the legs may not be effective in preventing dizziness, and it is not recommended during sleep in late pregnancy.
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