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 D
Explanation
Choice A rationale
Betamethasone, a corticosteroid, is not known to weaken uterine contractions. It is often administered to pregnant women at risk of preterm delivery to enhance fetal lung maturation and reduce complications associated with prematurity.
Choice B rationale
Betamethasone can potentially increase blood glucose levels, not decrease them. This is particularly relevant in women with gestational diabetes, as corticosteroids can exacerbate hyperglycemia.
Choice C rationale
Betamethasone does not typically decrease the fetal heart rate. Instead, it is used to help mature the lungs of the fetus.
Choice D rationale
Betamethasone is administered to pregnant women at risk of preterm delivery to enhance the production of surfactant in the fetal lungs. Surfactant is a substance that prevents the small air sacs in the lungs from collapsing, thereby aiding in the baby’s ability to breathe after birth.
Correct Answer is C
Explanation
Choice A rationale
It is not recommended to increase weight-bearing exercises during pregnancy. Weight-bearing exercises can put additional stress on the joints, which are already under strain due to the increased weight and changes in body shape during pregnancy.
Choice B rationale
It is not necessary to refrain from exercises that include stretching during pregnancy. In fact, gentle stretching can be beneficial to help alleviate some common discomforts of pregnancy such as backache and leg cramps.
Choice C rationale
Moderate exercise does improve circulation. Improved circulation can help reduce swelling, varicose veins, and feelings of fatigue, which are common during pregnancy.
Choice D rationale
It is not necessary to rest for 30 minutes before each new exercise. However, pregnant women should listen to their bodies and rest if they feel tired.
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