A patient at 37 weeks gestation is admitted with ruptured membranes. What is the first priority action for the nurse?

Correct Answer: B

Rationale: The correct answer is B: Check for cord prolapse. This is the first priority action because a prolapsed cord is a life-threatening emergency that requires immediate intervention to prevent fetal hypoxia and distress. The nurse should quickly assess for cord presentation by performing a vaginal exam and relieving pressure on the cord if present. Incorrect choices: A: Assess for signs of infection - While infection is a concern with ruptured membranes, it is not the immediate priority over checking for cord prolapse. C: Perform a vaginal exam to assess cervical dilation - Assessing cervical dilation can wait until after ruling out cord prolapse. D: Perform a vaginal examination to check for fetal descent - Fetal descent assessment is not urgent compared to checking for cord prolapse in this scenario.

Correct Answer: B

Rationale: The correct answer is B: assist with vacuum extraction. This intervention is appropriate when prolonged pushing has not resulted in progress during labor. Vacuum extraction helps facilitate the delivery of the baby by applying suction to the baby's head to assist with pulling them out. It is less invasive than a cesarean section and forceps delivery, making it a safer option in this scenario. Performing a cesarean section (choices A and C) would be considered if vacuum extraction is unsuccessful or contraindicated due to specific factors. Forceps delivery (choice D) is another option but is generally considered more invasive and carries higher risks compared to vacuum extraction.

Correct Answer: B

Rationale: The correct answer is B: Instruct the patient to increase fluid intake and stand slowly. This recommendation is appropriate because the patient is likely experiencing orthostatic hypotension due to the expanding uterus compressing blood vessels, leading to decreased blood flow to the brain when standing. Increasing fluid intake helps maintain blood volume, while standing slowly helps prevent sudden drops in blood pressure. A: Rising quickly can worsen dizziness by further decreasing blood flow to the brain. C: Resting in bed may not address the underlying issue of orthostatic hypotension and may lead to deconditioning. D: Avoiding standing for long periods may be impractical and may not address the need to maintain adequate blood volume and prevent sudden drops in blood pressure.

Correct Answer: A

Rationale: The correct answer is A: perform uterine massage. This is the priority because uterine massage helps to stimulate uterine contractions, which can help control bleeding in postpartum individuals. It is crucial to address the source of bleeding first. Performing a vaginal examination (choice B) may exacerbate bleeding. Evaluating blood loss (choice C) is important but not the initial step. Performing a uterine check (choice D) is vague and not as specific as uterine massage in addressing postpartum bleeding.

Correct Answer: A

Rationale: The primary purpose of performing an episiotomy during delivery is to reduce the risk of perineal trauma. Episiotomy is a surgical incision made in the perineum to widen the vaginal opening during childbirth, which can help prevent severe tearing of the perineal tissue. This procedure is performed to provide controlled and precise incision, reducing the likelihood of extensive tears that may lead to complications such as infection or prolonged healing time. It is not done to promote faster delivery, facilitate fetal descent, or provide immediate fetal oxygenation. These choices do not accurately reflect the main goal of episiotomy, which is to minimize perineal trauma.