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 task of recording strict nutritional content is within the scope of practice for an assistive personnel (AP). The AP can keep track of the client’s food and fluid intake and report this information to the nurse. This is important in this case as the client has not been eating and the provider has prescribed a regular tray with finger foods at each meal. The nurse can then use this information to assess the client’s nutritional status and make necessary adjustments to the care plan.
Choice B rationale
Administering medication, such as memantine, is not within the scope of practice for an AP. This task requires knowledge and skills related to pharmacology, assessment, and evaluation that are beyond the training of an AP. Therefore, this task should be performed by a licensed nurse.
Choice C rationale
Performing neurological checks is also not within the scope of practice for an AP. These checks involve assessing the client’s level of consciousness, orientation, and neurological function, which require advanced assessment skills. Therefore, this task should be performed by a licensed nurse.
Choice D rationale
Continuing the bowel training program could potentially be within the scope of practice for an AP, depending on the specific tasks involved. However, in this case, the family member has reported that the client is having more difficulty staying focused, which suggests that the bowel training program may need to be adjusted. This requires nursing judgment and therefore should be performed by a licensed nurse.
Correct Answer is D
Explanation
Choice A rationale
Sleeping on the left side does not directly help manage GERD. While it might help with digestion due to the positioning of the stomach, it is not a primary recommendation for GERD management.
Choice B rationale
Drinking milk is not a recommended way to soothe the stomach for a GERD patient. While milk might provide temporary relief from acid reflux, it could potentially stimulate the stomach to produce more acid, which can exacerbate GERD symptoms.
Choice C rationale
Waiting to go to bed for 1 hour after eating can help manage GERD. However, it is generally recommended to wait 2-3 hours after eating before lying down. This allows time for the stomach to empty and reduces the chance of stomach acid backing up into the esophagus.
Choice D rationale
Eating four to six small meals each day is a recommended way to manage GERD. Smaller meals are easier on the stomach, as they require less acid for digestion. This can help reduce the symptoms of GERD12.
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