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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Phyto menadione injectable, also known as vitamin K1, is commonly given to newborns to prevent hemorrhagic disease of the newborn (HDN), a bleeding disorder that can occur due to vitamin K deficiency in the first few days of life. Vitamin K is important for the production of clotting factors in the liver, and newborns are at risk of vitamin K deficiency because it does not cross the placenta well and their intestinal flora is not yet established. The other options do not accurately describe the purpose of administering Phyto menadione injectable to newborns.
Correct Answer is B
Explanation
The greatest priority for the practical nurse to monitor during the administration of epidural anesthesia is maternal blood pressure (BP). Epidural anesthesia can cause maternal hypotension due to vasodilation and decreased venous return, which can result in decreased fetal perfusion and oxygenation. Therefore, it is important for the practical nurse to monitor maternal BP frequently and promptly report any significant changes to the healthcare provider. Options A, C, and D are also important assessments, but they are not the priority in this scenario.
Therefore, options A, C, and D are not answers because they are not the priority assessment during the administration of epidural anesthesia.
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