You are working in the labor and delivery unit, you received several nursing reports.
Which patient should you assess first?
Select one:
A 27-year-old G2P1 woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago but feels normal fetal movements and not contractions are noted.
A 22-year-old. 9cm 100% +4. Who is requesting to go to the bathroom to have a bowel movement
A 32-year-old G4P3 woman at 27 weeks' gestation who noted scan vaginal bleeding today, after of having a sexual intercourse in the morning.
A 17-year-old. 2cm 80% -2. Who is crying and shows mild anxiety
The Correct Answer is B
a. A woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago with normal fetal movements is not a priority assessment as long as there are no signs of fetal distress.
b. A woman who is 9 cm dilated and fully effaced and is requesting to go to the bathroom to have a bowel movement is in the second stage of labor, which means that the cervix is fully dilated and the fetus is descending in the birth canal. The urge to have a bowel movement is a sign that the fetal head is pressing on the rectum and that delivery is imminent. This patient needs immediate attention and preparation for delivery.
c. A woman at 27 weeks' gestation who noted scant vaginal bleeding today after having sexual intercourse in the morning may be experiencing placenta previa or placental abruption but this is not a priority compared to the woman in option b who is yet to deliver.
d. A woman who is 2 cm dilated and 80% effaced and is crying and shows mild anxiety is not a priority assessment as long as there are no signs of fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. This may be necessary once the woman's condition stabilizes, but it is not the initial treatment.
b. This is not typically indicated for hyperemesis gravidarum.
c. This is the initial treatment for hyperemesis gravidarum to prevent dehydration and correct electrolyte imbalances.
d. This may be part of the treatment plan, but it is not the initial treatment.
Correct Answer is B
Explanation
a. A posterior presentation is when the fetus's back is toward the mother's back, and the fetal heart tones are usually heard on either side of the mother's abdomen.
b. A breech presentation is when the fetus's buttocks or feet are closest to the cervix. The fetal heart tones are usually heard above the umbilicus, at the midline, in a breech presentation.
c. A cephalic presentation is when the fetus's head is closest to the cervix, and the fetal heart tones are usually heard below the umbilicus, in either quadrant.
d. An oblique presentation is when the fetus's head or buttocks are angled toward one side of the pelvis, and the fetal heart tones are usually heard off-center, above or below the umbilicus.
e. A transverse presentation is when the fetus's spine is perpendicular to the mother's spine, and the fetal heart tones are usually heard on one side of the abdomen.
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