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
Detoxification can be a difficult and potentially dangerous process, and it's important for the client to receive proper monitoring and medication management during this time. The hospital is equipped to provide this level of care and support. The practical nurse should explain this to the client and emphasize the importance of receiving proper care during detoxification.
Correct Answer is B
Explanation
The action by the PN that is likely to facilitate accurate responses to personal and social history questions is to **request that the mother leave the exam room**. The personal and social history contains many areas of special sensitivity to adolescents including such issues as drug and alcohol use and sexual activity. The teen should provide the personal and social history, not the parent⁴.
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