A nurse has assessed a patient in labor.
The patient’s cervix is dilated 4 cm and 100% effaced.
The fetus is in the vertex presentation at -1 station.
The patient is walking to the bathroom and experiences a spontaneous rupture of membranes.
What is the nurse’s priority action?

Assess the amniotic fluid.

Walk the patient to the bathroom.

Call and inform the healthcare provider.

Assist the patient back to bed and initiate fetal monitoring.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Assessing the amniotic fluid is important after rupture of membranes, but it is not the immediate priority. The nurse should first ensure the safety of the mother and baby.

Choice B rationale

Walking the patient to the bathroom is not the immediate priority. After rupture of membranes, the patient should be assisted back to bed to prevent cord prolapse.

Choice C rationale

Calling and informing the healthcare provider is important, but it is not the first action. The nurse should first assist the patient back to bed and initiate fetal monitoring.

Choice D rationale

Assisting the patient back to bed and initiating fetal monitoring is the correct action. After rupture of membranes, the priority is to assess the fetal heart rate for any signs of distress, such as bradycardia, which could indicate cord prolapse.

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Correct Answer is B

Explanation

Choice A rationale

Hematuria, or blood in the urine, is not typically a symptom of postpartum endometritis.

Choice B rationale

Pelvic pain is a common symptom of postpartum endometritis. It is often one of the first symptoms to appear, along with lower abdominal pain and uterine tenderness.

Choice C rationale

While a moderate amount of dark red lochia with a bloody odor can be a normal part of the postpartum period, it is not specifically indicative of endometritis.

Choice D rationale

Localized area of breast tenderness is not typically a symptom of postpartum endometritis.

A. Cocaine use. B. Hypertension. C. Cigarette smoking. D. Blunt force trauma.

Correct Answer is B

Explanation

Choice B rationale

Hypertension is the most common risk factor for placental abruption. Hypertension can cause constriction of the blood vessels, including those in the placenta, which can lead to detachment of the placenta from the uterine wall.

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A nurse has assessed a patient in labor.The patient’s cervix is dilated 4 cm and 100% effaced.The fetus is in the vertex presentation at -1 station.The patient is walking to the bathroom and experiences a spontaneous rupture of membranes.What is the nurse’s priority action?

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Naxlex Comprehensive Predictor Exams

A nurse is evaluating a postpartum client for potential endometritis.Which of the following symptoms should the nurse identify as a need for further assessment?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse has assessed a patient in labor.
The patient’s cervix is dilated 4 cm and 100% effaced.
The fetus is in the vertex presentation at -1 station.
The patient is walking to the bathroom and experiences a spontaneous rupture of membranes.
What is the nurse’s priority action?