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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Epigastric discomfort is a common symptom of peptic ulcer disease, but it is not typically the symptom that should be prioritized. While discomfort can indicate an active ulcer, it does not necessarily signify a complication.
Choice B rationale
Hematemesis, or vomiting blood, is a serious symptom that could indicate a bleeding ulcer, which is a medical emergency. Therefore, this symptom should be prioritized.
Choice C rationale
Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease. However, it is not typically the symptom that should be prioritized as it does not necessarily indicate a serious complication.
Choice D rationale
Constipation is not typically associated with peptic ulcer disease and therefore should not be prioritized.
Correct Answer is B
Explanation
Choice B rationale
The umbilical cord normally contains two arteries and one vein. The arteries carry deoxygenated blood and waste products from the fetus to the placenta, and the vein carries oxygenated blood and nutrients from the placenta to the fetus.
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