As a woman enters the second stage of labor, her membranes spontaneously rupture. What action should the nurse take?
Check fetal heart rate
instruct her to bare down with the next contraction
Place her legs in stirrups
Test a sample of the amniotic fluid for meconium
The Correct Answer is A
A) Check fetal heart rate:
The first priority when a woman's membranes spontaneously rupture is to assess fetal well-being. The nurse should immediately check the fetal heart rate (FHR) after the rupture of membranes to evaluate for any signs of fetal distress. If there are any concerns regarding the FHR, further interventions may be needed, such as adjusting the maternal position or preparing for a possible emergent delivery. Monitoring the FHR will help guide subsequent decisions regarding care.
B) Instruct her to bear down with the next contraction:
While the second stage of labor involves pushing, it is important to wait for the appropriate signs of readiness before instructing the mother to bear down. The nurse should ensure the cervix is fully dilated and that fetal descent is progressing appropriately. Rushing into pushing too early or without proper readiness can lead to maternal and fetal complications.
C) Place her legs in stirrups:
Placing the mother’s legs in stirrups is typically done once she is in the active phase of pushing (typically when the cervix is fully dilated and fetal descent is ready). It is not the first priority immediately after the membranes rupture. The nurse should first assess the fetal heart rate and ensure the woman is comfortable and ready to push before assuming the lithotomy position or placing her legs in stirrups.
D) Test a sample of the amniotic fluid for meconium:
Testing the amniotic fluid for meconium should be done if there is concern that the amniotic fluid may be stained, as meconium in the amniotic fluid can be a sign of fetal distress. However, the first action after the membranes rupture is to check the fetal heart rate. If the FHR is normal, further actions, like testing the fluid, may follow, but the priority remains assessing fetal well-being.
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Related Questions
Correct Answer is B
Explanation
A) "There are specific pain management options that you need to use":
It’s important to respect the client's autonomy and work collaboratively to explore pain management options that align with their cultural values and medical safety. A more open, client-centered approach would be more beneficial.
B) "We will work with you to incorporate the practices that are safe for you and your fetus.":
This statement acknowledges the client's cultural preferences while ensuring that safety is the priority. The nurse is offering to collaborate with the client to explore pain management options that align with their values, within the scope of what is medically safe for both the mother and the fetus. It promotes a partnership approach, which is critical in maternity care.
C) "You will need to discuss this with the provider.":
While the provider may ultimately be involved in deciding specific pain management options, this statement dismisses the nurse's role in supporting the client’s cultural preferences. Nurses can play an active role in initiating and facilitating these conversations with clients and helping them express their preferences to the provider. It is not solely the provider's responsibility.
D) "It is better to use pain management options that have been researched.":
While evidence-based practices are important, this statement could be seen as dismissive of the client's cultural preferences. It fails to address the importance of individualized care and overlooks the possibility of integrating safe, culturally relevant pain management practices alongside researched methods. A balanced approach that respects both cultural values and medical safety is crucial.
Correct Answer is ["C","E","H","I"]
Explanation
Findings that require follow-up:
Uterus boggy at 24 hr postpartum:
A boggy uterus indicates poor uterine contraction, which can lead to postpartum hemorrhage. Effective uterine contraction is crucial to prevent excessive bleeding after delivery, and this finding warrants immediate intervention, such as fundal massage or administering uterotonic medications.
Lochia rubra with foul odor:
Foul-smelling lochia is a sign of potential infection, often indicative of endometritis, which is an infection of the uterine lining. The presence of this odor requires prompt follow-up and possibly antibiotic treatment to prevent further complications.
Elevated temperature (38.3°C/100.9°F) at 24 hr postpartum:
A postpartum fever may indicate infection, such as endometritis or a urinary tract infection (UTI). This fever should be investigated further to determine the cause and appropriate treatment, as untreated infections can lead to serious complications.
Increased heart rate (105/min) at 24 hr postpartum:
Tachycardia in the postpartum period can be a sign of infection or early signs of hemodynamic instability, possibly due to blood loss or infection. Close monitoring is necessary, and the healthcare provider should be notified to evaluate the cause and initiate treatment if necessary.
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