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 practical nurse (PN) should recognize that a newborn whose mother has poorly controlled type 1 diabetes mellitus and is exhibiting grunting with mild sternal retractions is exhibiting signs of patent ductus arteriosus. Patent ductus arteriosus is a condition in which the ductus arteriosus, a blood vessel that connects the pulmonary artery to the aorta, fails to close after birth. This can result in abnormal blood flow between the aorta and pulmonary artery, leading to respiratory distress.
Hypothyroidism (Option A) and hyperinsulinemia (Option C) are conditions that can occur in newborns, but they do not typically present with grunting and sternal retractions.
Ventral septal defect (Option D) is a congenital heart defect that can cause respiratory distress, but it is not specifically associated with maternal diabetes.
Correct Answer is B
Explanation
This is the most appropriate intervention for the PN to implement when approaching a client who is exhibiting compulsive behavior. By allowing time for the behavior, the PN acknowledges the client's need to perform the behavior and avoids creating further stress for the client. Redirecting the client to other activities can also help to refocus the client's behavior and prevent further compulsive behavior.
Encouraging the client to be calm and relax for a little while (A) may not be effective in managing the compulsive behavior.
Teaching the client thought-stopping techniques and ways to refocus behaviors (C) and assisting the client to identify stimuli that precipitate the activity (D) are interventions that may be used in the long term, but they may not be immediately effective in managing the client's behavior in the moment.
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