A laboring gravida 2, para 1 is being cared for on the family birth unit. Her cervix is currently 5
cm dilated and 100% effaced. The fetus is at -2 station and cephalic in a left occiput anterior
position. The patient calls the nurse to the room and reports a large gush of fluid with her most
recent contraction. The nurse assesses that the patient's membranes are ruptured and that the
amniotic fluid is green and watery. What is the most important nursing intervention at this
time?
Ans: Assess FHR to check for any change in baseline or any abnormal patterns.
Quiz A 17-year-old primigravida is admitted in early labor. Her cervix is 2 to 3 cm dilated and
100% effaced. The fetus is cephalic, and the presenting part is at -1 station. Her membranes are
intact. The patient is holding her boyfriend's hand tightly and breathing rapidly with each
contraction. She tells the nurse in a shaky voice, "I'm so nervous. I've never been in a hospital
before. I don't know anything about labor or if I can do this." What is an appropriate nursing
diagnosis for this patient?
Ans: Anxiety related to unfamiliar environment and lack of birth preparation
Quiz A primigravida at 40 weeks' gestation is admitted to the labor unit in latent labor. Her
prenatal history does not indicate any risk factors. Her initial vital signs are temperature of
cm dilated and 100% effaced. The fetus is at -2 station and cephalic in a left occiput anterior
position. The patient calls the nurse to the room and reports a large gush of fluid with her most
recent contraction. The nurse assesses that the patient's membranes are ruptured and that the
amniotic fluid is green and watery. What is the most important nursing intervention at this
time?
Ans: Assess FHR to check for any change in baseline or any abnormal patterns.
Quiz A 17-year-old primigravida is admitted in early labor. Her cervix is 2 to 3 cm dilated and
100% effaced. The fetus is cephalic, and the presenting part is at -1 station. Her membranes are
intact. The patient is holding her boyfriend's hand tightly and breathing rapidly with each
contraction. She tells the nurse in a shaky voice, "I'm so nervous. I've never been in a hospital
before. I don't know anything about labor or if I can do this." What is an appropriate nursing
diagnosis for this patient?
Ans: Anxiety related to unfamiliar environment and lack of birth preparation
Quiz A primigravida at 40 weeks' gestation is admitted to the labor unit in latent labor. Her
prenatal history does not indicate any risk factors. Her initial vital signs are temperature of
