A client who is a primigravida at 40 weeks gestation is contracting every 2 minutes and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the practical nurse (PN) implement?
Call the rapid response team to the bedside.
Check the time the last PRN narcotic analgesic was given.
Report to charge nurse that the client is near to delivery.
Ask the husband to leave the room for a while.
The Correct Answer is C
The practical nurse should report to the charge nurse that the client is near delivery, as the client's signs indicate that she is in the transition phase of labor and is likely to deliver soon. The PN should also assess the client's vital signs, fetal heart rate, and pain level, and prepare the delivery equipment.
The husband can be asked to provide emotional support to the client during labor.
The rapid response team may be called in case of a medical emergency, but this is not indicated based on the information given.
Checking the time, the last PRN narcotic analgesic was given is also not indicated at this point, as the client is close to delivery and may not have time for medication to take effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Vitamin tablets are unlikely to cause significant harm to the esophagus if the child vomits after ingesting them. However, toilet bowl cleaner and kerosene are corrosive substances that can cause serious damage to the esophagus and other tissues if ingested.
An unknown substance cannot be evaluated for potential harm to the esophagus.
In any case, the mother should be advised to seek immediate medical attention for her child if they have ingested any potentially harmful substance.
The PN should also follow their facility's policies and procedures for managing cases of poisoning or suspected poisoning.
Correct Answer is A
Explanation
The practical nurse (PN) should obtain a serum glucose level to assess the client's blood sugar level, which can help to determine if the client is experiencing hyperglycemia or diabetic ketoacidosis (DKA). Anorexia, drowsiness, and polydipsia, along with the reported frequent urination and bedwetting, are symptoms of hyperglycemia or DKA.
Offering age-appropriate toys (B) or suggesting diapers for bedtime use (C) are not appropriate actions for the PN to take in this situation.
Bringing orange juice and crackers (D) may help to increase the client's blood sugar level in the short term, but it does not address the underlying issue and may exacerbate the client's symptoms if she is experiencing hyperglycemia or DKA.
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