During a nursing assessment the woman with rupture

Correct Answer: A

Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.

Correct Answer: B

Rationale: Ensuring the baby's lips are sealed around the areola promotes effective milk transfer and reduces pain.

Correct Answer: A

Rationale: Late decelerations on the fetal monitor strip indicate uteroplacental insufficiency. These decelerations occur after the peak of a contraction, and the fetus may not receive enough oxygen-rich blood during contractions. Uteroplacental insufficiency can lead to fetal hypoxia and acidosis if not addressed promptly. It is important for the nurse to take appropriate steps to improve fetal oxygenation, such as repositioning the mother, administering oxygen, and adjusting IV fluids. If late decelerations persist, further interventions may be necessary to ensure the well-being of the fetus.

Correct Answer: B

Rationale: Avoiding fluids during meals can help reduce nausea by minimizing gastric distension.

Correct Answer: B

Rationale: A hard, rigid abdomen and severe pain are classic signs of placental abruption, requiring urgent intervention.