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 B
Explanation
The best indicator to the practical nurse (PN) that the community bicycle safety education program was effective is that the number of students wearing bicycle helmets increased by 10%. Wearing a helmet while riding a bicycle is an important safety measure that can help prevent head injuries in the event of an accident. An increase in the number of students wearing helmets indicates that the program was successful in promoting this safety behavior. The other findings listed may also provide useful information about the effectiveness of the program, but the increase in helmet use is the most direct and measurable indicator of success.
Correct Answer is D
Explanation
The first intervention the PN should implement is to **sit and offer to listen to the client's concerns**. It is important to approach the client in a calm and non-threatening manner and to establish a rapport with him. Offering to listen to his concerns can help the client feel heard and understood, and can help build trust between the client and the PN.
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