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 A
Explanation
Choice A rationale
The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.
Choice B rationale
This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.
Choice C rationale
This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.
Choice D rationale
While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.
Correct Answer is A
Explanation
Choice A rationale
Asking the partner to talk about his difficulties in caring for the client is the nurse’s priority. This intervention allows the nurse to assess the partner’s emotional state and provide appropriate support and resources.
Choice B rationale
Recommending that the partner place the client in a long-term care facility may not be the best initial intervention. The decision to place a loved one in a long-term care facility is complex and involves many factors. The nurse should first assess the partner’s needs and concerns before making such a recommendation.
Choice C rationale
Telling the partner to call a family meeting to get help may be a helpful suggestion, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.
Choice D rationale
Suggesting that the partner see a counselor to help him cope with his exhaustion may be a helpful intervention, but it is not the nurse’s priority. The nurse should first assess the partner’s emotional state and needs before suggesting specific interventions.
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